Practice management (d)
Summary of Indicators
||D. Practice Management
|Individual healthcare professionals have access
to information on local procedures relating to Child Protection
|There are clearly defined arrangements for backing
up computer data, back-up verification, safe storage of back-up
tapes and authorisation for loading programmes where a computer
|The Hepatitis B status of all doctors and relevant
practice-employed staff is recorded and immunisation recommended
if required in accordance with national guidance
|The arrangements for instrument sterilisation
comply with national guidelines as applicable to primary care
|The practice offers a range of appointment times
to patients, which as a minimum should include morning and afternoon
appointments five mornings and four afternoons per week, except
where agreed with the PCO
|Person specifications and job descriptions are
produced for all advertised vacancies
|The practice has systems in place to ensure regular
and appropriate inspection, calibration, maintenance and replacement
of equipment including:
. A defined responsible person
. Clear recording
. Systematic pre-planned schedules
. Reporting of faults
|The practice has a policy to ensure the prevention
of fraud and has defined levels of financial responsibility
and accountability for staff undertaking financial transactions
(accounts, payroll, drawings, payment of invoices, signing cheques,
petty cash, pensions, superannuation etc.)
|The practice has a protocol for the identification
of carers and a mechanism for the referral of carers for social
|There is a written procedures manual that includes
staff employment policies including equal opportunities, bullying
and harassment and sickness absence (including illegal drugs,
alcohol and stress), to which staff have access
Individual healthcare professionals have
access to information on local procedures relating to Child Protection
Management 1.1 Practice guidance
Awareness of the existence of local Child Protection procedures
is mandatory and all healthcare professionals should be able to
access a copy.
Management 1.2 Written evidence
There should be a description of how local procedures are accessed.
Management 1.3 Assessment visit
Access to local procedures should be demonstrated.
Management 1.4 Assessors' guidance
The assessors should check with team members what action they would
take if they had reason to suspect that a child might be being abused,
including which local procedures they would refer to and how.
There are clearly defined arrangements for
backing up computer data, back-up verification, safe storage of
back-up tapes and authorisation for loading programmes where a computer
Management 2.1 Practice guidance
The practice should have a written policy which defines who is responsible
for backing up data, how it is done and how often it is done. It
is good practice to keep weekly and monthly backups as well as daily
backups using a rotation of back-up tapes or their equivalent. It
is good practice to keep a log. Tapes should be renewed at specified
intervals. Verification of backups should also be carried out at
regular specified intervals, especially in paper-light or paperless
practices. Tapes should be stored in a fireproof safe, with a procedure
in place for back-up tapes being stored off site in order to ensure
confidentiality. The policy should also define the individuals who
are authorised to load new software programmes.
Management 2.2 Written evidence
There should be written policy regarding:
- backing up data and verification, including the frequency of that
- storage on and off site
- authorisation to load programmes. (Grade A)
Management 2.3 Assessment visit
The back-up and loading arrangements should be demonstrated.
Management 2.4 Assessors' guidance
The arrangements for back-up, verification and storage procedures
should be checked with the responsible staff member. It is important
to ascertain that staff are aware of the procedure for authorisation
for loading new software.
The Hepatitis B status of all doctors and
relevant practice-employed staff is recorded and immunisation recommended
if required in accordance with national guidance
Management 3.1 Practice guidance
Useful guidance on Hepatitis B risks and immunisation is contained
in the UK Health Departments' publication "Guidance for Clinical
Health Care Workers: protection against infection with blood borne
viruses - recommendations of the Expert Advisory Group on AIDS and
the Advisory Group on Hepatitis" (www.doh.gov.uk/pub/docs/doh/chcguidl.pdf).
The BMA supplies an interactive CD ROM "Bloodborne viruses
and infection control: a guide for health care professionals".
(1998) This also provides access to the Health Department's guidance
Under the Health and Safety at Work etc Act (1974) (HSWA), GPs are
legally obliged to make sure that all employees receive appropriate
training and know the procedures for working safely. They must also
carry out risk assessments and these could include assessing procedures
under the Control of Substances Hazardous to Health Regulations
1994 (COSHH). These regulations would cover employees who have direct
contact with patients' blood, other potentially infectious bodily
fluids or tissues. Immunisation of doctors and staff that have direct
contact with these substances is recommended in the above regulations.
The Health Department guidance "Protecting health care workers
and patients from Hepatitis B" and the 1996 addendum (see above
reference to the website, Annex 1) states that all health care workers
who perform exposure prone procedures (EPPs) should be immunised.
They should have their response to the vaccine checked and non-responders
to vaccination should be investigated for infection in order to
minimise risk to patients. This guidance also states that workers
whose Hepatitis B status is unknown should be tested before carrying
Immunisation provides protection in up to 90% of patients vaccinated,
but is not a substitute for good infection control procedures.
The BMA website provides a specimen Hepatitis B immunisation policy
in the general practice staff (non-medical) specimen handbook. Advice
on suitable immunisation policies can also be obtained from the
Occupational Health Service, which works with reference to guidelines
published in "Immunisation against Infectious Disease"
(see Annex 1 in the above website).
Management 3.2 Written evidence
There should be evidence that the Hepatitis B status of all staff
is known. (Grade C)
Management 3.3 Assessment visit
Questioning should take place on the system to check Hepatitis B
Management 3.4 Assessors' guidance
It should be confirmed that evidence is available that the Hepatitis
B status of all doctors and relevant practice-employed staff has
been recorded and that there is a mechanism for recommending (and
recording any recommendation) regarding vaccination to the doctor
or staff member, including checking response to vaccination.
The arrangements for instrument sterilisation
comply with national guidelines as applicable to primary care
Management 4.1 Practice guidance
The Health Departments in each Country will issue guidance relating
to instrument sterilisation which will be agreed with the General
Management 4.2 Written evidence
There must be a policy for instrument sterilisation.
Management 4.3 Assessment visit
The sterilisation arrangements should be inspected.
Management 4.4 Assessors' guidance
Definitive guidance is yet to be finalised with the departments
The practice offers a range of appointment
times to patients, which as a minimum should include morning and
afternoon appointments five mornings and four afternoons per week,
except where agreed by the PCO
Management 5.1 Practice guidance
In practices which operate with open surgeries, this would mean
that the practice should have a range of times of availability equivalent
to the appointment range in the indicator. Patients should be offered
a reasonable range of appointment times, which are advertised to
them. The practice's appointment system should normally offer as
a minimum the range of appointments described in the practice leaflet.
In remote and rural areas, for example, or in some single-handed
practices, the range of appointment availability described in the
indicator will not be appropriate. In these circumstances, the practice
should agree its availability with the PCO and this should be advertised
in the practice leaflet. Evidence that this has been agreed should
be made available to the assessor.
Management 5.2 Written evidence
The practice leaflet should be scrutinised for evidence of appointment
times. (Grade A)
Management 5.3 Assessment visit
The practice leaflet and appointment book should be checked.
Management 5.4 Assessors' guidance
The advisers should check that the practice advertises in the practice
leaflet a range of appointment times which corresponds to the indicator.
The availability of such appointments should be confirmed by looking
at a randomly selected week in the appointment book/appointment
system. In practices offering a more limited range of appointment
availability, the practice should provide evidence that the PCO
has agreed the range on offer.
Person specifications and job descriptions
are produced for all advertised vacancies
Management 6.1 Practice guidance
Production of a person specification and job description at the
time of identifying a vacancy not only ensures that the practice
maximises its chances of employing the right person for the job,
but protects the practice against the risk of being in breach of
the following acts: the Sex Discrimination Act, Equal Pay Act, Disability
Discrimination Act and Race Relations Act. The government is currently
working on draft legislation covering discrimination on the grounds
of sexual orientation, religion and age. It is also good practice
not to discriminate on these grounds during the recruitment process.
Useful guidance on how to recruit without discrimination can be
found on the following web sites:
- The Equal Opportunities Commission Code of Practice - Sex Discrimination
If unsuccessful candidates for a post were to claim that they had
been discriminated against on the grounds of sex, then they could
take their complaint to an employment tribunal. The tribunal would
take into account whether the Code of Practice was relevant to the
circumstances of the case and, if so, failure by the practice to
follow the code would be taken into consideration in its determination.
The ACAS website also gives guidance on Equal Opportunities (www.acas.org.uk).
- The Disability Discrimination Act: Code of Practice for the elimination
of discrimination in the field of employment against disabled persons
or persons who have had a disability at www.disability.gov.uk
This Code of Practice applies to employers with 15 or more employees.
This threshold excluding small firms will be reviewed. The Code
explains the Act in the form of answering frequently asked questions
and clearly explains employers' obligations. It covers advertising,
the selection process, terms and conditions of service and "reasonable
- The Commission for Race Equality: Employment Code of Practice
The Code of Practice covers advertising, selection/shortlisting,
uniforms, language and other areas.
Management 6.2 Written evidence
The person specification and job description of the last person
employed after 1 April 2003 should be available. (Grade B)
Management 6.3 Assessment visit
The assessment should involve questioning on the person specification
and job description of the last person employed after 1 April 2003.
Management 6.4 Assessors' guidance
The assessors should check that the practice's approach to recruitment
has included production of a person specification and job description
relevant to the actual vacancy. Discussion could include the process
used for drawing up the person specification eg who was involved
and the opportunity for reviewing the job description. The practice
could demonstrate understanding of how the production of the specification
and job description demonstrates good employment practice.
The practice has systems in place to ensure
regular and appropriate inspection, calibration, maintenance and
replacement of equipment including:
- A defined responsible person
- Clear recording
- Systematic pre-planned schedules
- Reporting of faults
Management 7.1 Practice guidance
The evidence for this criterion may form part of the statutory risk
assessment activity which takes place under the Health and Safety
at Work Regulations 1999 (Management Regulations). Comprehensive
guidance on risk assessment can be found in the Health and Safety
Executive's website on www.hse.gov.uk.
The website provides a free booklet "Five steps to risk
This website also contains a free leaflet "Maintaining portable
electrical equipment in offices and other low risk environments".
This contains guidance on the appropriate person to inspect and
maintain equipment in relation to the equipment's associated risks
as well as suggested intervals between inspections and maintenance.
For example, a printer may be inspected and maintained by a "competent"
person with enough knowledge and training, who need not be an electrician.
This is only one of several free leaflets available on the website;
others may also be relevant to the individual practice's circumstances.
The schedule should clearly identify who has overall responsibility,
who is the appropriate individual to inspect/maintain/calibrate
each piece of equipment, the intervals between inspections and the
system for reporting faults.
Management 7.2 Written evidence
Details should be given of the system to ensure regular and appropriate
inspection, calibration, maintenance and replacement of equipment
meeting the stated criteria. (Grade B)
Management 7.3 Assessment visit
A review of equipment requiring maintenance and of the log of inspection
and maintenance should be undertaken.
Management 7.4 Assessors' guidance
The practice should have in place a system which includes risk assessment
of equipment and a schedule of inspection, calibration and maintenance.
This should include electrical equipment.
The responsible person will not always be the person actually carrying
out the inspection; this should be specified in the schedule.
The intervals between inspection, calibration and maintenance will
be different for various types of equipment dependent on their associated
level of risk. Inspection, calibration and maintenance should be
There should be a clear system for reporting faults.
The practice should be able to provide a written record of inspection,
calibration and maintenance for some randomly selected pieces of
equipment. It would be useful to consider a range of equipment from
small items (eg printer) up to larger items such as a steriliser
The practice has a policy to ensure the prevention
of fraud and has defined levels of financial responsibility and
accountability for staff undertaking financial transactions (accounts,
payroll, drawings, payment of invoices, signing cheques, petty cash,
pensions, superannuation, etc.)
Management 8.1 Practice guidance
The practice should have a policy which clearly defines the levels
of financial responsibility in the practice. This will include a
description of the activities which are carried out by the practice
manager (eg payroll), other staff (eg petty cash) and partners (eg
calculation of drawings) and will make clear the extent of responsibility.
For example, the senior receptionist may be responsible for managing
the petty cash on a day-to-day basis and may produce a monthly statement
for the practice manager along with handing over cash for banking.
The practice manager may then be responsible for checking this and
for recording and banking the cash. The practice manager may have
overall responsibility for ensuring the management of the petty
The line of accountability for finance in the practice should also
be clearly defined. For example, a particular partner may be identified
as being responsible on behalf of the partnership for financial
management. This responsibility may be delegated to the practice
manager, who may have responsibility for day to day book-keeping,
banking and other record-keeping, reconciling the bank statements
and preparing regular financial statements for the finance partner.
The finance partner will then be responsible to the partnership
as a whole.
A fraud prevention policy may cover the following areas:
- a defined partner is responsible with the practice manager for
business and finance affairs
- bank accounts are only operable with at least two signatories.
The number of non-partners who are signatories should be restricted
- the same individual should where ever possible not be both payee
and authorising signatory
- the practice should avoid undue reliance on one member of staff
for financial and business controls
- staff are never paid in cash for work undertaken
- there is a written procedure for the removal of cash from petty
- all income and expenditure are recorded and reconciled with the
- purchases of equipment etc are only made with the prior approval
of a partner - a level of expenditure may be agreed and set above
which approval should be sought
- all transfers between accounts are properly authorised and can
- all cheques signed should be accompanied by appropriate documentation
- the practice should ensure where possible that one individual
does not place an order, authorise the invoice and sign the cheque.
Management 8.2 Written evidence
The policy is provided. (Grade A)
Management 8.3 Assessment visit
Questioning is carried out on the steps taken to prevent fraud.
Management 8.4 Assessors' guidance
The practice's fraud prevention policy is discussed with the practice
manager and the partner(s) with financial responsibility.
The practice has a protocol for the identification
of carers and a mechanism for the referral of carers for social
Management 9.1 Practice guidance
The practice should produce a procedure for how carers are identified
and a referral protocol to social services for assessment and carers
with specific needs.
Management 9.2 Written evidence
The protocol is available. (Grade A)
Management 9.3 Assessment visit
The policy is discussed.
Management 9.4 Assessors' guidance
The assessors should enquire of various team members what action
they would take when they identify that a carer may benefit from
social services involvement.
There is a written procedures manual that
includes staff employment policies including equal opportunities,
bullying and harassment and sickness absence (including illegal
drugs, alcohol and stress), to which staff have access
Management 10.1 Practice guidance
It is good employment practice to have established written procedures,
which are available to staff, so that both staff and employer are
clear about the steps to be taken if a problem arises. As well as
the policies mentioned, the manual could include the Disciplinary
and Grievance Procedure.
Useful guidance on writing these policies can be found as follows:
- Equal Opportunities Policy: The Equal Opportunities Commission
- Guidelines for Equal Opportunities Employers on
can also be found on the ACAS web site on www.acas.org.uk.
This information can also be obtained from ACAS Reader Ltd, PO Box
16, Earl Shilton, Leicester LE9 8ZZ (tel 01455 852225). The Department
for Education and Skills also publishes an Equal Opportunities Ten
Point Plan for Employers giving practical advice on implementing
equal opportunities policies.
- Bullying and Harassment: ACAS as above.
- IHM Healthcare Management Code at ihm.org.uk.
- IHM Diversity Group recommendations for Recruitment and Selection.
- Sickness Absence: ACAS as above, including their booklet entitled
"Absence and Labour Turnover".
- BMA guidance on managing absence at bma.org.uk.
Management 10.2 Written evidence
Employment policies should be recorded. (Grade B). Policies should
be consistent with current legislation and indicate a date when
the policy has been reviewed.
Management 10.3 Assessment visit
The procedures manual should be inspected.
Management 10.4 Assessors' guidance
The procedures manual should contain dated copies which are made
available to staff of the policies relating to their employment.
It should be confirmed with employed staff that they are aware of
the content of the procedures manual and its whereabouts.