SPQF
6

Workforce and Team Capability

Our team has the qualifications, skills, and support to deliver safe, high-quality care.

Version 1.0 - First Edition

Why This Domain Matters

A specialist practice is only as good as the people who work in it - and that includes everyone, not just the clinicians. The receptionist who triages a phone call from a distressed patient. The practice nurse who preps the procedure room and recognises that the oxygen cylinder is running low. The practice manager who notices that a staff member has been increasingly absent and checks in before it becomes a crisis. The billing officer who spots that a Medicare claim does not match the service delivered.

In most specialist practices, staffing is lean. There are few redundancies. When one person is away, their knowledge goes with them. When a new staff member starts, onboarding is often "follow Sarah around for a day and ask questions." Performance conversations happen informally if they happen at all. Training budgets are discretionary. And workplace culture is whatever the principal practitioner sets by personal example - which can be outstanding or deeply problematic, with very little in between.

This domain does not ask specialist practices to build a human resources department. It asks them to be deliberate about the basics: making sure people are qualified for what they do, trained for what they need, supported when things are hard, and managed fairly when things go wrong. For practices where the team works well, most of this will be easy to demonstrate. For practices where the team dynamic is strained, this domain will show you where to start.

Quality Statements

We have enough people with the right skills to deliver safe care and run the practice effectively.

Indicators

  • 6.1.1 The practice has assessed the staffing levels and skill mix required to deliver its services safely. This assessment considers clinical volumes, the complexity of services provided, leave coverage, and the administrative workload. It is reviewed when services or volumes change.
  • 6.1.2 There is a clear allocation of roles and responsibilities across the team. Every staff member can describe their role and who they report to. Key functions - appointment management, billing, results handling, infection control, equipment maintenance - have a nominated responsible person and a backup arrangement.
  • 6.1.3 The practice has a plan for managing foreseeable staff absences, including annual leave, parental leave, and extended sick leave. For critical roles (practice manager, practice nurse, principal practitioner), the plan identifies who steps in and what handover is required.
  • 6.1.4 Where the practice uses casual, agency, or locum staff, there is a process for ensuring those staff are briefed on practice systems, emergency procedures, and key policies before they begin working.
  • 6.1.5 Staffing arrangements comply with applicable industrial instruments, including the Health Professionals and Support Services Award (or relevant enterprise agreement), National Employment Standards, and any jurisdictional requirements for health worker ratios or supervision.

Suggested Evidence

  • Staffing assessment or workforce plan
  • Organisational chart or role allocation document
  • Leave cover and succession arrangements for critical roles
  • Casual, agency, and locum briefing process
  • Evidence of award or agreement compliance

We verify that every person we employ or engage is suitable to work in a healthcare setting.

Indicators

  • 6.2.1 The practice has a recruitment process that includes, at a minimum, verification of identity, a check of qualifications relevant to the role, and a reference check from a recent employer. For clinical staff, AHPRA registration verification is completed before commencement (as also covered in Domain 1.3).
  • 6.2.2 Police checks or working with children checks are obtained where required by jurisdictional legislation or where the role involves unsupervised access to vulnerable patients. The practice understands when these checks are legally required versus best practice.
  • 6.2.3 The practice verifies the right to work in Australia for all employees and contractors.
  • 6.2.4 Where the practice engages contractors or visiting practitioners, the engagement arrangements are documented. This includes evidence of their own professional indemnity insurance, ABN, and any relevant registration or credentialing.
  • 6.2.5 Pre-employment check records are retained securely in the staff member's personnel file.

Suggested Evidence

  • Recruitment checklist
  • AHPRA verification records for clinical staff
  • Police check and WWCC records where applicable
  • Right to work verification
  • Contractor engagement agreements
  • Personnel file structure and contents list

Every new team member receives a structured introduction to our practice before they start delivering care or performing their role independently.

Indicators

  • 6.3.1 The practice has a documented orientation program for new staff. The program covers, at a minimum, the practice layout, emergency procedures (including emergency exits, fire extinguisher locations, and clinical emergency response), key policies (infection control, privacy, incident reporting), clinical and administrative systems, and the team structure.
  • 6.3.2 The orientation is completed before the new staff member begins performing their role independently. For clinical staff, this includes supervised familiarisation with the practice's clinical systems, equipment, and procedural protocols.
  • 6.3.3 New staff are given access to the practice's policy and procedure manual and know where to find it. They are encouraged to ask questions and are assigned a point of contact during their initial period.
  • 6.3.4 Orientation completion is documented and signed off by the new staff member and their supervisor or the practice manager. Any gaps identified during orientation are addressed with a follow-up plan.
  • 6.3.5 The orientation program is reviewed periodically to ensure it remains current, particularly when systems, policies, or premises change.

Suggested Evidence

  • Orientation program outline or checklist
  • Signed orientation completion records
  • Evidence of follow-up for identified gaps
  • Orientation review and update history

We invest in our team's skills and knowledge so they can perform their roles safely and effectively.

Indicators

  • 6.4.1 The practice identifies the mandatory and role-specific training requirements for each staff member. At a minimum, this includes BLS certification for clinical staff, infection control training, privacy and confidentiality training, and fire and emergency training. Additional requirements depend on the role and the services the practice provides.
  • 6.4.2 Training completion is tracked. The practice maintains a training register or matrix that records what training each staff member has completed, when it was completed, and when it is next due.
  • 6.4.3 The practice supports the professional development of its staff beyond mandatory training. This may include attendance at conferences, in-house education sessions, cross-training, or external courses. Support is proportionate to the size and resources of the practice.
  • 6.4.4 When new equipment, software, or clinical processes are introduced, relevant staff are trained before the change goes live. Training is documented.
  • 6.4.5 Clinical staff, including nurses and allied health professionals employed by the practice, are supported to meet their own registration body's continuing professional development requirements.
  • 6.4.6 The practice holds or participates in regular team meetings or in-service education sessions. These serve both operational and learning purposes and are documented.

Suggested Evidence

  • Training register or matrix
  • Mandatory training completion records (BLS, IPC, fire, privacy)
  • Professional development records and support arrangements
  • Training records for new equipment, software, or process changes
  • Team meeting or in-service education records

We set clear expectations, provide regular feedback, and address performance issues fairly.

Indicators

  • 6.5.1 Every staff member has a position description that sets out their responsibilities, reporting relationships, and the key competencies required for the role. Position descriptions are reviewed when the role changes.
  • 6.5.2 The practice conducts performance reviews at least annually for all staff. Reviews are a two-way conversation that covers what is going well, areas for development, and goals for the coming period. Reviews are documented.
  • 6.5.3 Feedback is not limited to annual reviews. The practice encourages a culture of regular, informal feedback - both positive and constructive - throughout the year.
  • 6.5.4 Where performance concerns arise, the practice has a documented process for addressing them. The process is fair, consistent, and proportionate. It includes an opportunity for the staff member to respond and, where appropriate, a support plan before escalating to formal action.
  • 6.5.5 Where a performance concern relates to clinical competence or patient safety, it is escalated immediately to the clinical governance lead and, if required, to AHPRA under mandatory notification provisions. The practice understands the threshold for mandatory notification and does not delay reporting to manage the issue internally.
  • 6.5.6 The practice maintains personnel files for all staff that include position descriptions, employment contracts, pre-employment check records, training records, performance reviews, and any formal correspondence related to conduct or performance.

Suggested Evidence

  • Position descriptions for all roles
  • Annual performance review records
  • Performance management policy or process
  • Examples of support plans for performance concerns
  • Personnel file contents checklist
  • Evidence of understanding mandatory notification thresholds

Our practice fosters a respectful, inclusive, and psychologically safe workplace.

Indicators

  • 6.6.1 The practice has a code of conduct or set of behavioural expectations that applies to all staff, including practitioners. The code addresses respectful communication, anti-bullying, anti-discrimination, and expected standards of professional behaviour.
  • 6.6.2 Staff know how to raise concerns about workplace behaviour - including behaviour by a practitioner or practice owner - without fear of retaliation. There is a clear process, and staff are confident it will be taken seriously.
  • 6.6.3 The practice does not tolerate bullying, harassment, sexual harassment, or discrimination. Where such behaviour is reported, it is investigated and addressed. The practice understands its obligations under the Sex Discrimination Act, Fair Work Act, and relevant state or territory anti-discrimination legislation.
  • 6.6.4 The practice actively promotes a culture where raising safety concerns, reporting incidents, and admitting errors is encouraged, not punished. This applies to clinical and non-clinical staff equally.
  • 6.6.5 Interprofessional respect is expected. Clinical hierarchies do not justify disrespectful or dismissive behaviour toward staff in non-clinical or junior roles. The principal practitioner or practice owner models this standard.
  • 6.6.6 The practice periodically checks in on team culture - whether through anonymous staff surveys, structured team discussions, or other feedback mechanisms. Results are considered and acted upon where concerns are identified.

Suggested Evidence

  • Code of conduct or behavioural expectations document
  • Process for raising workplace behaviour concerns
  • Anti-bullying and anti-harassment policy
  • Evidence of leadership modelling expected behaviour
  • Staff survey or culture check-in results and actions

We recognise that the health and wellbeing of our team directly affects the safety and quality of care we provide.

Indicators

  • 6.7.1 The practice acknowledges the wellbeing of its staff as a governance responsibility, not just a personal matter. Workload, rostering, and leave arrangements are managed with staff wellbeing in mind.
  • 6.7.2 Staff are encouraged to take their leave entitlements. Patterns of excessive hours, cancelled leave, or persistent presenteeism are identified and addressed by the practice manager.
  • 6.7.3 The practice provides or facilitates access to employee support services. For practices too small to fund a formal Employee Assistance Program (EAP), this may include information about external support services such as the Doctors' Health Advisory Service, Nurse & Midwife Support, or Beyond Blue's healthcare worker resources.
  • 6.7.4 The practice has a process for supporting staff following a distressing clinical event - such as a patient death, a serious complication, an aggressive patient, or involvement in a complaint or coronial inquiry. Support is offered proactively, not only in response to a request.
  • 6.7.5 Practitioners within the practice are encouraged to maintain their own health, including having a regular GP. The practice does not create conditions - through workload, culture, or financial pressure - that discourage practitioners from seeking help for their own health concerns.
  • 6.7.6 The practice considers the physical ergonomics of the work environment, including workstation setup, repetitive movement risks for procedural clinicians, and the physical demands placed on nursing and administrative staff.

Suggested Evidence

  • Leave tracking and workload monitoring
  • EAP or external support service information provided to staff
  • Post-incident support process documentation
  • Evidence of wellbeing discussed at team meetings or reviews
  • Ergonomic assessment or workstation setup records

Not sure what counts as evidence?

The evidence guide provides concrete examples of what evidence looks like at each maturity level for every indicator in this domain.

View Evidence Guide

Ready to assess your practice?

Rate your practice against every indicator in this domain using the self-assessment tables.

Self-Assessment Guide

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Evidence Guide All Resources
PDF Downloads: Framework Self-Assessment Evidence Guide
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