Foundation Standard changes

Updates 20 December 2024

4.1 Responsiveness to diversity: Added to resources a case study on how Lyttleton Health Centre completed this indicator

8.1 Clinical governance and leadership: Added the following content to the guidance

New Zealand’s Health Quality and Safety Commission (HQSC) have newly published ‘Collaborating for quality: a framework for clinical governance | He mahi ngātahi kia kounga: He anga hei whakahaere whare haumanu'.

This document provides high-level guidance for implementing clinical governance in health and disability services in Aotearoa New Zealand and intends to replace the previous clinical governance guidance released in 2017.

The College and HQSC are working together on the transition process to the new framework, in the meantime, please continue to use the 2017 Clinical Governance guidelines, which is included in the resources below.

9.1 Repeat prescribing: Added to guidance: Please note that although audits are to be run annually, if an audit shows that the policy is not being adhered to, it is expected that an improvement action (such as reviewing the policy with the team and/or prescriber/s, is followed by another audit to ensure the policy is being followed.

13.2 Hazardous substances: Reworded the content under the heading 'Inventory of hazardous substances' From:

Before creating an inventory, it’s a good idea to review your hazardous substances and if possible, try to reduce the substances you have.

There are three main things you need to do:

-make an initial inventory (list) of all the hazardous substances used at your
workplace including hazardous waste (if any)

-keep your inventory up-to-date and accurate

-make sure your inventory is readily accessible to emergency services workers.

The simplest way to prepare an inventory is to use the Hazardous Substances Calculator on the WorkSafe website.

To:

Developing hazardous substance inventories and mitigating risks:

1. Visit the WorkSafe site and use the calculator to determine which substances have a high level of risk. Enter these into the WorkSafe inventory.
2. Make sure your WorkSafe inventory and list of other hazardous substances used in the workplace are readily accessible to emergency services workers.
3. Make a practice inventory (list) of the remaining hazardous substances including hazardous waste (if any).
4. Add the Worksafe inventory and the practice inventory to your Hazards and Risks register.
5. Keep your WorkSafe inventory, your practice inventory and the Hazards and Risks register up to date

14.1 Evacuation drills and a documented emergency evacuation scheme: Added to guidance: Documented evacuation drills and debriefs every 6 months for the previous 18 months should be provided as evidence.

Training requirements page, under the heading 'Simplifying the uploading of training documents'

From:

For practices with over 20 team members you may choose to only upload the following in entirety:

-cardiopulmonary resuscitation (CPR) certificates for all clinicians

-annual practising certificates (APCs)

-police vetting certificates and the associated risk summary.

To

Practices with over 20 team members who choose to adopt the simplified process, need only upload the following in entirety:

-cardiopulmonary resuscitation (CPR) certificates for all clinicians

-annual practising certificates (APCs)

-Authorised vaccinator certificates

-police vetting certificates and the associated risk summary.

Quality Programmes resources: Developing a Policy and/or procedure. Added under document control: Electronic signatures are acceptable.

Update 27 September 2024

• 11.6 guidance: Removed reference to the 2018 version of AS/NZ:3003 . The reason being is that electricians will inspect to the most current ratified AS/NZ:3003 standard.

Update 15 August 2024

• Uploaded an updated version of a SAMPLE Child Protection policy and procedure to the Quality resources

Update 26 July 2024

• 9.1 guidance: updated the Repeat prescribing template so that all responses should be YES. This will make it easier to audit.
• 15.1 guidance: Added resource The Children's action plan' to the policy section.
• Foundation Standard resources: Added a team member Induction template
• Foundation Standard overview page: Under the heading 'Team members': Clarified the makeup of the team and the training required.

Update 20 July 2024

• 12.2 guidance: Removed "audit to check compliance against the policy". The recommended audit check in the NZ Standard 4304:2002 is no longer available, so removed as a requirement in the Health Care Waste policy.

Update 30 May 2024

• 13.3 guidance: It is recommended that practices remain on the 2017 Adverse Events Policy until the College signals a new date to transition from the 2017 to the 2023 Adverse Events Reporting Policy. The College continues to work with HQSC on applying this policy to general practice. (changed from: Practices have until July 2024 to transition from the 2017 to the 2023 Adverse Events Reporting Policy.)

Updates November 2023

• 11.6: Updated information on portable RCDs not to regulation.
• 8.2 guidance: Guidance content on delivering clinical governance updated in collaboration with HQSC
• How to structure a policy (resource): Changes to content of document control to clarify the requirements

Updates October 2023

• 3.2 guidance: Provided more clarity on requirement(s) for Treaty of Waitangi training
• 8.1 guidance: Added to resources an updated version of power point slides on implementing clinical governance.