Section A:
Factors affecting patients
Section Contents Page Number
Indicator Group 1: Respecting the needs and rights of patients
Indicator A.1.1 A3
The practice demonstrates its commitment to respecting the needs and rights
of its practice population
Indicator A.1.2 A7
The practice maintains the privacy of patient information in accordance with Bill 31
Indicator A.1.3 A11
The practice encourages patient suggestions and feedback into service planning
Indicator A.1.4 A14
The practice respects patients’ rights to formally complain
Indicator A.1.5 A16
The practice honours its commitment to recognising the diversity of its patients
Indicator A.1.6 A19
Mandatory reporting occurs in accordance with legislation in the family practice
Indicator Group 2: Access and availability
Indicator A.2.1 A21
Information about practice services is available for patients
Indicator A.2.2 A24
The practice makes provision to ensure patients are able to access 24-hour care,
7 days a week
Indicator A.2.3 A27
The practice has an effective system to monitor waiting times for investigations and
referrals to ensure that patients are receiving them in a timely manner
Indicator A.2.4 A29
The practice uses a system that assists the practice team to identify and provide an
appropriate response to emergencies/urgent medical conditions
Indicator A.2.5 A31
The practice team ensures that patients are provided with information to enable
them to make informed decisions about their care
Section Contents Page Number
Indicator A.2.6 A34
The practice provides educational information on health promotion and
disease prevention to patients
Indicator A.2.7 A36
Initial and repeat prescribing in the absence of a visit is accurate, appropriate
and timely
Indicator Group 3: There are no barriers to access
Indicator A.3.1 A39
Patients can easily access the practice using the telephone system
Indicator A.3.2 A41
Patients can access the practice for advice or appointments appropriately
Indicator A.3.3 A43
Patient visits are effective and efficient
Indicator A.3.4 A45
The practice premises are clearly signposted and physically accessible
Indicator Group 4: Promoting patient-centredness
Indicator A.4.1 A48
The practice promotes quality provider-patient relationships
Indicator A.4.2 A51
The practice is patient-centred
Section A
Factors affecting patients
Indicator Group 1 Respecting the needs and rights of patients
Indicator A.1.1 The practice demonstrates its commitment to respecting
the needs and rights of its practice population
Criteria A.1.1.1 êê The practice has a written policy that describes how
it provides services to patients
A.1.1.2 êê The practice team is familiar with the Canada Health Act,
Professional Codes of Ethics, Geneva Declaration, and Four
Principles of Family Medicine
A.1.1.3 êê The practice team is familiar with its contractual requirements
(the model of practice of family medicine)
A.1.1.4 ê The patient has the right to have someone else in the room
during an examination or consultation
A.1.1.5 ¶ The practice demonstrates its dedication to comprehensive care
by providing the full basket of services as outlined in the
PCCCAR Report
A.1.1.6 ê The practice complies with guidelines regarding new patients
Section A – Factors affecting patients
Indicator Group 1 – Respecting the needs and rights of patients
Indicator A.1.1
The practice demonstrates its commitment to respecting the needs and rights of its practice population
The purpose of this indicator is to establish evidence of the practice commitment to servicing its practice population and its recognition of its legal obligations, contractual requirements, ethical duties and dedication to comprehensive care
Criteria:
A.1.1.1 êêThe practice has a written policy that describes how it provides services to patients
Interpretation
· The practice has a written policy regarding service hours, after hours service, types of service, etc. (see Indicator A.2.1 for information about practice services available to patients)
· The practice has clearly posted guidelines and policies about payment for uninsured services
A.1.1.2 êêThe practice team is familiar with the Canada Health Act, Professional
Codes of Ethics, Geneva Declaration and Four Principles of Family Medicine
Interpretation
· The practice understands and implements the elements of the Canada Health Act with respect to Universality and Portability, and ensures that patients are aware of their health insurance coverage. In the Canada Health Act there are specific instructions about Universality (eligibility for OHIP coverage, registration requirements, and other categories of individual coverage) and Portability (minimum waiting periods, coverage during absences in Canada and absences outside Canada )
A.1.1.3 êêThe practice team is familiar with its contractual requirements (the
model of practice of family medicine)
Interpretation
· The practice understands the model of family practice within which it works, and communicates its contractual obligation for the model of practice with the patients. Patients should know whether they have signed a contract or agreement. This would include Fee-For-Service, Health Service Organization, Family Health Team, Primary Care Network, Family Health Network, Family Health Group, Community Health Centre, Community Service Contract, Northern Group Funding Plan (see Glossary).
A.1.1.4 êThe patient has the right to have someone else in the room during an
examination or consultation
Interpretation
· The patient is informed of the right to have a third party present during an examination or consultation
· When a patient is accompanied to the practice by a third person, it is important to ensure that the patients consents to the presence of that person in an examination or consultation
· The clinic room is furnished to accommodate family members
· Female staff are available to assist with examinations or consultations
A.1.1.5¶The practice demonstrates its dedication to comprehensive care by
providing the full basket of services as outlined in the PCCCAR Report
Interpretation
· All members of the practice are familiar with the practice’s dedication to provide the full basket of services as outlined in the PCCCAR Report
· If a practice limits its scope, there are arrangements with other providers and patients can be referred to these providers for these services, e.g. obstetrics, palliative care, hospital care, etc.
A.1.1.6êThe practice complies with guidelines regarding new patients
Interpretation
· Newly registered patients are offered a consultation to ascertain details of their past medical and family histories, social factors including occupation, lifestyle, and measurements of risk factors
· Those findings are recorded in the medical records, and patients with significant medical conditions are reviewed
Further Information
CMA Code of Ethics 2004
http://www.cma.ca/multimedia/staticcontent/HTML/N0/l2/where_we_stand/CodeofEthics04.pdf
1996 CMA Code of Ethics Annotated for Psychiatrists
http://www.cpa-apc.org/Publications/Position_Papers/annotatedCodeOfEthics/codeOfEthics.html
Provincial and Territorial Health Care Insurance Plans 2002-2003
http://www.hc-sc.gc.ca/medicare/Documents/CHA0203-prov-all.pdf
Canada Health Act (5 criteria)
http://www.hc-sc.gc.ca/medicare/home.htm
Health Card requirements
http://www.health.gov.on.ca/english/public/program/ohip/ohipfaq_mn.html
MOHLTC website: Questions and answers re OHIP eligibility
Paths to Equal Opportunity
http://www.equalopportunity.on.ca/eng_g/index.asp
Ontario Association of the Deaf
http://deafontario.ca/oad/
Good Medical Practice for Physicians (Revalidation UK)
http://www.rcpe.ac.uk/news/gmpfp/good_mpfp_rev.pdf
Ontario Human Rights Commission has Policy and Guidelines on Disability and the Duty to Accommodate
http://www.ohrc.on.ca/english/publications/disability-policy.shtml
Cultural competence: Essential measurement of quality for managed care organizations
Annals of Internal Medicine.1996:124;10;919-921
http://www.annals.org/cgi/content/full/124/10/919
OCP – Labelling Prescriptions for the Visually Challenged
http://www.ocpinfo.com/client/ocp/OCPHome.nsf/web/Labelling+Prescriptions+for+the+Visually+Challenged!OpenDocument
Section A: Factors affecting patients
Indicator Group 1 Respecting the needs and rights of patients
Indicator A.1.2 The practice maintains the privacy of patient information
in accordance with Bill 31
Criteria A.1.2.1 êê The practice team have had training to implement Bill 31- the
Health Information Protection Act and the Quality of Care Information Protection Act
A.1.2.2 êê The practice has a designated contact person responsible for
monitoring privacy issues
A.1.2.3 êê Patient consent is obtained and recorded for the disclosure of
personal information and the release of notes to another party
A.1.2.4 êê The practice follows reasonable steps to ensure records are
protected
A.1.2.5 êê The practice has established and maintains appropriate
information practices and informs its patients about these
practices
A.1.2.6 êê The practice has a written statement and/or privacy policy
A.1.2.7 êê The practice collects and stores patients’ personal information in
compliance with the law
A.1.2.8 êê The practice takes reasonable steps to protect personal health
information that is transferred to others
A.1.2.9 êê Members of the practice team who have access to medical
records have signed a confidentiality agreement
Section A – Factors affecting patients
Indicator Group 1 – Respecting the needs and rights of patients
Indicator A.1.2
The practice maintains the privacy of patient information in accordance with Bill 31
The purpose of this indicator is to identify how the practice system maintains patient privacy in accordance with Bill 31
Criteria:
A.1.2.1 êêThe practice team has had training to implement Bill 31- the Health
Information Protection Act and the Quality of Care Information Protection Act
Interpretation
· All members of the practice team must be familiar with Bill 31 and have taken the necessary steps to ensure that they are abiding by the intent of the law
A.1.2.2 êêThe practice has a designated contact person responsible for monitoring
privacy issues
Interpretation
· Designated contact person
· Process is identified for collection, use and disclosure of personal health information
A.1.2.3 êêPatient consent is obtained and recorded for the disclosure of personal
information and the release of notes to another party
Interpretation
· The purpose of this criterion is to determine that appropriate consent has been obtained
· Use the sample consent form in the Physician Privacy Toolkit to confirm that consent is recorded in the chart
A.1.2.4 êêThe practice follows reasonable steps to ensure records are protected
Interpretation
· Records are protected against theft, loss and unauthorized access, copying, modification, use, disclosure and disposal
A.1.2.5 êêThe practice has established and maintains appropriate information
practices and informs its patients about these practices (see OMA toolkit
http://www.oma.org/phealth/privacymain.htm)
Interpretation
· The practice posts a policy about how it has it has established and maintains appropriate information practices
A.1.2.6 êêThe practice has a written statement and/or privacy policy
Interpretation
· There is a written policy made available to all patients on:
- the information practices
- the contact person information
- the access, correction, inquiry and complaints procedure
· There are procedures to:
- Identify when a use or disclosure of personal health information is beyond what is described in the written statement
- Notify affected patients about such a use or disclosure make and keep notes of such a use or disclosure in or linked to the affected personal health record
A.1.2.7 êêThe practice collects and stores patients’ personal information in compliance with the law
Interpretation
· The practice defines scopes of practice and job responsibilities for health care professionals and staff to identify who requires personal health information, what information they require, and for what purpose
· The practice is aware of who collects what personal health information (to limit duplication of collection); about the consent requirements for collection; about restricting the collection of personal health information to the purposes for which you have consent or which are permitted or required by law; and about restricting the collection of personal health information to the information that is required
· The practice regularly reviews collection practices to ensure compliance with the Act
· The practice is aware of how records are protected against theft, loss and unauthorized access, copying, modification, use, disclosure, retention and disposal
A.1.2.8 êêThe practice takes reasonable steps to protect personal health
information that is transferred to others
Interpretation
· The practice can describe and show what reasonable steps are taken to protect health information transferred to others
A.1.2.9 êêMembers of the practice team who have access to medical records have signed a confidentiality agreement
Interpretation
· A practice log that records team members & others signed commitment to confidentiality of patient records
· The log should record: name, date employment commenced, signed agreement
Further Information
Ontario’s Bill 31 received third reading in the legislature on May 17, and will be proclaimed into law effective November 1, 2004. Bill 31 consists of two schedules — the Health Information Protection Act (HIPA), and the Quality of Care Information Protection Act (QCIPA).
http://www.oma.org/phealth/privacy/b031ra.pdf
Ontario Medical Association provides guidance in the Physician Privacy Toolkit and a Physician Privacy Statement September 2004
http://www.oma.org/phealth/privacymain.htm
http://www.oma.org/phealth/privacy/PrivacyStatement04.pdf
CPSO - A Guide to Current Medical Record-Keeping Practices
http://www.cpso.on.ca/Publications/medrecbk.htm
CPSO Policy on Confidentiality and Access to Patient Information
http://www.cpso.on.ca/Policies/confidentiality.htm
CMA PrivacyWizardTM
Create handouts for your patients, review and enhance office privacy practices and better understand your privacy obligations.
www.cma.ca/privacywizard.htm or call 1888 855 2555
OHA’s Quality of Care Information Protection Act Toolkit
http://oha.com/client/OHA/OHA_LP4W_LND_WebStation.nsf/resources/QCIPAToolkit/$file/QCIPAToolkit.pdf
CMPA - Protecting personal health information: An overview for physicians
http://www.cmpa-acpm.ca/portal/pub_index.cfm?LANG=E&URL=cmpa%5Fdocs%2Fenglish%2Fresource%5Ffiles%2Fon%5Fthe%5Frecord%2Fcommon%2F2002%2F09%2Fcom%5Fon%5Fthe%5Frecord%5F2002%5F09%2De%2Ehtml
Canadian Consumer Information Gateway
http://consumerinformation.ca/app/oca/ccig/abstract.do?language=eng&abstractNo=OR000029&text=personal+health+information+privacy+act&topic=CAT6.TOPICS.ROOT&language=eng
College of Dietitians of Ontario – Privacy Code
http://www.cdo.on.ca/en/home%20pop-ups/Privacy/PRIVACY%20CODE%20revised%20Jan%202005.htm
College of Nurses of Ontario – Privacy Code
http://www.cno.org/prac/privacy/index.htm
Canadian Pharmacists Association – Pharmacist’s Personal Information Privacy Code
http://www.pharmacists.ca/content/hcp/resource_centre/practice_resources/pdf/Pharmacist_PIPCode.pdf
Ontario College of Social Workers and Social Service Workers - Code of Ethics, Principle V: Confidentiality
http://www.ocswssw.org/sections/pdf/1.6B%20code%20of%20ethics%20english.pdf
Section A: Factors affecting patients
Indicator Group 1 Respecting the needs and rights of patients
Indicator A.1.3 The practice encourages patient suggestions and
feedback into service planning
Criteria A.1.3.1 ¶ The practice encourages patient suggestions and feedback on
services provided
A.1.3.2 ¶ Suggestions, feedback and follow-up changes and improvements
are incorporated in the practice quality improvement process
A.1.3.3 ¶ Information about use of patient suggestions and feedback is
communicated back to the practice team and patients
A.1.3.4 ¶ The practice has carried out a patient satisfaction questionnaire
within the last three years
Section A – Factors affecting patients
Indicator Group 1 – Respecting the needs and rights of patients
Indicator A.1.3
The practice encourages patient suggestions and feedback into service planning
The purpose of this indicator is to create opportunities for patients to provide suggestions and feedback for improving and planning services
Criteria:
A.1.3.1¶The practice encourages patient suggestions and feedback on services
provided
Interpretation
· Information about encouragement and methods used to invite patient suggestions and feedback on services provided, e.g. suggestion boxes
A.1.3.2¶ Suggestions, feedback, follow-up changes and improvements are
incorporated in the practice quality improvement process
Interpretation
· The practice documents all suggestions, feedback, follow-up changes and system improvements
A.1.3.3¶Information about use of patient suggestions and feedback is
communicated back to the practice team and patients
Interpretation
· How patient feedback is communicated back to the practice team is documented