7
Self-Assessment
Practice Environment and Infrastructure
Rate your practice against each indicator. Use this as a working reference - print it, copy it into a spreadsheet, or work through it on screen.
Version 1.0 - First Edition
Maturity Levels
Not in Place
Not done, or unaware of the requirement
Developing
Done inconsistently or informally
Established
Done reliably with evidence
Excelling
Actively reviewed and improved
7.1
Consulting and Procedure Room Standards
Our rooms are designed, equipped, and maintained to support safe clinical practice.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.1.1 | All consulting rooms provide adequate space for clinical examination | ||||
| 7.1.2 | Consulting rooms include appropriate privacy screening and acoustic separation | ||||
| 7.1.3 | Adequate lighting is available for clinical assessment in all consulting rooms | ||||
| 7.1.4 | Procedure rooms are equipped with appropriate clinical furniture and fittings for the procedures performed | ||||
| 7.1.5 | Procedure rooms have documented equipment lists that are reviewed at least annually | ||||
| 7.1.6 | Emergency equipment appropriate to the risk profile of the practice is available, accessible, and maintained (including resuscitation equipment where applicable) | ||||
| 7.1.7 | Oxygen and suction equipment (where present) is checked and serviced in accordance with manufacturer recommendations | ||||
| 7.1.8 | Clinical equipment is calibrated and maintained in accordance with applicable standards or manufacturer instructions | ||||
| 7.1.9 | Equipment maintenance records are kept and reviewed | ||||
| 7.1.10 | Sharps containers, clinical waste bins, and hand hygiene facilities are accessible in all consulting and procedure rooms | ||||
| 7.1.11 | Temperature-sensitive medications and products are stored appropriately (where applicable) | ||||
| 7.1.12 | Crash trolley or emergency kit is checked at defined intervals and documented |
7.2
Accessibility and Wayfinding
Every patient can access and navigate our practice safely and with dignity.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.2.1 | The practice entry is step-free or has an accessible alternative entry route | ||||
| 7.2.2 | Accessible toilet facilities are available to patients (or their location is clearly communicated at booking) | ||||
| 7.2.3 | Consulting rooms can accommodate patients using wheelchairs, mobility aids, or bariatric equipment | ||||
| 7.2.4 | Signage is clear, readable, and guides patients from entry to reception and waiting areas | ||||
| 7.2.5 | The practice has a documented process for supporting patients who require additional assistance to access the building or rooms | ||||
| 7.2.6 | Booking and reception staff are aware of accessibility considerations and can assist patients proactively | ||||
| 7.2.7 | Patients with sensory impairments (hearing or vision) are accommodated in the practice communication and appointment process | ||||
| 7.2.8 | Interpreter requirements are identified at booking and appropriate arrangements are made (see also Domain 4) | ||||
| 7.2.9 | Car parking or public transport access information is provided to patients at the time of booking | ||||
| 7.2.10 | Emergency exit routes are clearly marked and accessible to patients with disabilities |
7.3
Cleaning Hygiene and Environmental Standards
Our premises are clean, safe, and free from environmental hazards.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.3.1 | A documented cleaning schedule exists and is followed for all clinical and non-clinical areas | ||||
| 7.3.2 | Cleaning products used are appropriate to the surfaces and areas being cleaned (including clinical-grade products in procedure areas) | ||||
| 7.3.3 | Cleaning records or logs are maintained | ||||
| 7.3.4 | Cleaning staff receive induction and ongoing training appropriate to clinical environments | ||||
| 7.3.5 | Enhanced cleaning is carried out after any contamination event | ||||
| 7.3.6 | The practice has a documented process for pest management | ||||
| 7.3.7 | Ventilation in consulting and procedure rooms is adequate and maintained | ||||
| 7.3.8 | Waiting areas and reception are maintained to a clean and presentable standard | ||||
| 7.3.9 | Physical hazards in the practice (e.g. trip hazards, trailing cables, unstable furniture) are identified and addressed | ||||
| 7.3.10 | The practice complies with applicable work health and safety requirements in relation to the physical environment |
7.4
Reusable Medical Device Reprocessing and Sterilisation
We reprocess reusable instruments in accordance with applicable standards and in a way that protects patient and staff safety.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.4.1 | A documented reprocessing procedure exists for all reusable medical devices used in the practice | ||||
| 7.4.2 | Reprocessing is conducted in accordance with AS/NZS 4815 (office-based healthcare) or AS/NZS 4187 (where a more complex procedure profile applies) | ||||
| 7.4.3 | Reprocessing is conducted in a dedicated area with appropriate separation of clean and dirty workflow | ||||
| 7.4.4 | Staff responsible for reprocessing have received documented training in the procedure | ||||
| 7.4.5 | Sterilisation equipment (autoclave) is tested, validated, and serviced in accordance with manufacturer instructions and applicable standards | ||||
| 7.4.6 | Sterilisation cycle records are maintained and include cycle parameters and load identification | ||||
| 7.4.7 | Instrument packaging is inspected prior to use and out-of-date or damaged items are removed from circulation | ||||
| 7.4.8 | Single-use devices are not reused | ||||
| 7.4.9 | The practice has a defined process for managing a reprocessing failure or instrument recall | ||||
| 7.4.10 | Where reprocessing is outsourced, the provider's credentials and compliance are verified and documented |
7.5
Waste Management
We manage clinical and general waste safely, lawfully, and in a way that protects staff, patients, and the environment.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.5.1 | Clinical, sharps, pharmaceutical, and general waste streams are clearly separated and labelled | ||||
| 7.5.2 | Waste management procedures are documented and followed by all clinical and cleaning staff | ||||
| 7.5.3 | Sharps containers are approved, correctly labelled, not overfilled, and disposed of via a licensed contractor | ||||
| 7.5.4 | Clinical waste (including pathological waste) is collected by a licensed clinical waste contractor at appropriate intervals | ||||
| 7.5.5 | Waste disposal documentation (including contractor consignment notes) is retained for the required period | ||||
| 7.5.6 | Pharmaceutical waste (including expired medications) is disposed of via appropriate channels and not placed in general waste | ||||
| 7.5.7 | The practice complies with applicable state or territory waste regulations | ||||
| 7.5.8 | Staff are trained in waste segregation and the management of contamination incidents |
7.6
IT Infrastructure and Cybersecurity
Our IT systems are fit for purpose, kept up to date, and protected against foreseeable threats.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.6.1 | Clinical and administrative software is licenced, current, and supported by the vendor | ||||
| 7.6.2 | Operating systems on all practice devices are within vendor support lifecycle (no end-of-life OS in use on clinical devices) | ||||
| 7.6.3 | Automatic security updates and patches are applied to all devices and systems | ||||
| 7.6.4 | Antivirus or endpoint protection software is installed and active on all practice devices | ||||
| 7.6.5 | Practice Wi-Fi separates clinical and administrative networks from patient guest access | ||||
| 7.6.6 | Multi-factor authentication (MFA) is enabled for access to clinical software, email, and remote access systems | ||||
| 7.6.7 | Access to clinical systems is role-based and user accounts are deactivated promptly when staff leave | ||||
| 7.6.8 | Passwords are managed in accordance with current guidance (minimum complexity requirements; not shared between systems; not written on physical notes near devices) | ||||
| 7.6.9 | Patient data is not stored on personal devices unless encrypted and subject to a documented access policy | ||||
| 7.6.10 | The practice has a documented cybersecurity incident response procedure | ||||
| 7.6.11 | Staff have received cybersecurity awareness training in the past 24 months | ||||
| 7.6.12 | The practice is enrolled in My Health Record and meets its obligations for secure messaging in accordance with the Australian Digital Health Agency standards (where applicable) | ||||
| 7.6.13 | The practice has considered and documented its obligations under the Notifiable Data Breaches scheme |
7.7
Clinical and Administrative System Reliability
We manage system disruptions in a way that maintains continuity and patient safety.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.7.1 | A documented data backup procedure exists and is tested at defined intervals | ||||
| 7.7.2 | Backups are stored in a location separate from primary systems (including at least one offsite or cloud-based copy) | ||||
| 7.7.3 | The practice has a documented downtime procedure for when the practice management system is unavailable | ||||
| 7.7.4 | Staff are aware of the downtime procedure and know where to find it | ||||
| 7.7.5 | Clinical notes can be accessed (in read-only mode at minimum) during a system outage | ||||
| 7.7.6 | The practice has a documented process for restoring normal operations and reconciling data following a downtime event | ||||
| 7.7.7 | Hardware failures and system outages are logged and reviewed for patterns | ||||
| 7.7.8 | The practice has identified its IT support provider and has a current support contract or arrangement in place |
7.8
Business Continuity Planning
We have plans to maintain safe operations and protect patient welfare when normal operations are disrupted.
| Ref | Indicator | Not in Place | Developing | Established | Excelling |
|---|---|---|---|---|---|
| 7.8.1 | A documented business continuity plan (BCP) exists for the practice | ||||
| 7.8.2 | The BCP identifies credible disruption scenarios relevant to the practice (e.g. extended power outage, premises unavailability, key staff absence, major system failure, natural disaster) | ||||
| 7.8.3 | The BCP assigns clear roles and responsibilities for each scenario | ||||
| 7.8.4 | The BCP includes procedures for contacting and managing patients affected by a disruption | ||||
| 7.8.5 | The BCP includes procedures for maintaining access to patient records during a disruption | ||||
| 7.8.6 | The BCP is reviewed at least annually and following any significant disruption event | ||||
| 7.8.7 | The practice has tested at least one element of the BCP (e.g. data restoration, downtime procedure) in the past 12 months | ||||
| 7.8.8 | Contact details for essential services (IT support, utilities, building manager, clinical waste contractor, locum agencies) are documented and accessible without relying on systems that may be affected by the disruption | ||||
| 7.8.9 | The practice has considered its obligations to patients with ongoing clinical needs in the event of an extended closure | ||||
| 7.8.10 | Critical physical infrastructure (power, heating/cooling, water) is assessed for risk and mitigation options are documented |
Not sure what counts as evidence?
The evidence guide provides concrete examples for every indicator in this domain.