Glossary

A unique 11-digit identifier issued by the Australian Government to businesses. Every specialist practice operating as a business must have one.

A unique nine-digit number issued by ASIC to every company registered in Australia. Required if your practice operates as a company (Pty Ltd). Not required for sole traders or partnerships.

The government body that registers companies and manages the companies register. If your practice operates as a Pty Ltd company, ASIC is where it is registered and where annual company statements must be lodged.

A document issued by an insurer confirming that an insurance policy is current and providing key details: policy number, insurer, insured parties, sum insured, and expiry date. This is the document you should hold on file for each practitioner's professional indemnity insurance and for the practice's own policies.

The primary Commonwealth legislation governing employment relationships in Australia. Covers minimum employment standards (National Employment Standards), modern awards, unfair dismissal, and general workplace protections. Relevant to position descriptions, employment contracts, performance management, and disciplinary procedures.

The schedule of services subsidised by the Australian Government through Medicare. Each service has an item number, a description, a schedule fee, and a Medicare benefit amount. Practitioners must ensure that the item number billed accurately reflects the service provided. Incorrect billing is one of the most common compliance issues in specialist practice.

A Department of Health program that provides financial incentives to general practices for activities that improve quality of care. PIP payments are a major reason GP practices pursue accreditation. There is no equivalent PIP for specialist practices — which is one of the reasons specialist practice accreditation has not been pursued historically.

A portable device that analyses heart rhythm and delivers an electrical shock to restore normal rhythm during cardiac arrest. Modern AEDs are designed for use by non-specialists and provide voice prompts. Batteries and pads have expiry dates and must be checked regularly.

Advanced resuscitation training covering airway management, cardiac arrest rhythms, defibrillation, and emergency drug administration. Expected for practitioners performing procedures under sedation or in settings where patients may deteriorate rapidly. Certification is typically valid for 12–24 months depending on the training provider.

The body that publishes evidence-based guidelines for resuscitation practice in Australia. ARC guidelines inform what emergency equipment and training your practice should have.

The expert advisory body that provides recommendations on immunisation to the Australian Government. ATAGI guidelines specify which vaccinations are recommended for healthcare workers.

Foundational resuscitation training covering recognition of cardiac arrest, calling for help, chest compressions, rescue breathing, and AED use. The minimum level of resuscitation training expected for all clinical staff in a specialist practice. Certification is typically valid for 12 months.

A structured communication framework used for clinical handover and escalation. Provides a consistent format for conveying critical patient information: who you are and who the patient is (Identify), what is happening now (Situation), relevant history (Background), your clinical assessment (Assessment), and what you think should happen next (Recommendation).

A legal and ethical requirement that patients agree to treatment or procedures based on a genuine understanding of what is proposed, including the nature of the treatment, expected benefits, material risks, available alternatives, and the consequences of declining. It is a process of communication, not merely a signature on a form. The legal standard in Australia (from Rogers v Whitaker) requires disclosure of material risks — those that a reasonable person in the patient's position would want to know about.

A legal concept from the High Court decision in Rogers v Whitaker (1992). A risk is 'material' if a reasonable person in the patient's position would be likely to attach significance to it, or if the practitioner is or should be aware that the particular patient would be likely to attach significance to it. This is the standard for informed consent in Australia — practitioners must disclose material risks, not just common risks or risks they personally consider important.

An event that could have caused harm but did not — either because it was intercepted before reaching the patient, or because the patient was not harmed by chance. Examples: wrong patient file opened but error caught before the consultation, medication drawn up at the wrong dose but identified before administration, pathology result misfiled but found before it was needed. Near-misses are as important to report and analyse as actual incidents because they reveal system weaknesses before harm occurs.

The process of communicating honestly and transparently with a patient (and/or their family) when something has gone wrong during their care. Based on the Australian Open Disclosure Framework, it involves: acknowledging the event, expressing regret, explaining what happened and what is being done to prevent recurrence, and offering support. Open disclosure is not the same as admitting legal liability — most Australian jurisdictions provide legal protection for apologies and expressions of regret made during open disclosure.

The landmark High Court of Australia decision that established the 'material risk' standard for informed consent. The court held that a practitioner must warn a patient of a material risk inherent in a proposed treatment — defined as a risk that a reasonable person in the patient's position would be likely to attach significance to, or that the practitioner knows or should know the particular patient would attach significance to. This replaced the earlier 'reasonable doctor' standard and shifted the focus to what the patient needs to know, not what the doctor thinks is important.

A structured investigation method used after serious clinical incidents to identify the underlying systemic factors that contributed to the event — not just the immediate cause but the deeper organisational, process, and environmental factors that made the event possible. Involves mapping the sequence of events, identifying contributing factors at each step, and developing recommendations to address the root causes. Proportionate to serious incidents (SAC 1 or 2) — not every incident requires an RCA.

A rating system used to classify the severity of clinical incidents, typically on a 1–4 scale where SAC 1 is the most serious (death or severe permanent harm) and SAC 4 is a near-miss or no harm. The severity rating determines the level of investigation required — SAC 1 incidents typically require a formal root cause analysis, while SAC 4 incidents may only need a brief review.

A term describing healthcare workers who experience significant emotional distress, guilt, shame, or self-doubt after being involved in a patient safety event. The 'first victim' is the patient; the 'second victim' is the clinician or staff member. Second victims often receive no support because all attention focuses on the patient. The SPQF addresses this through staff wellbeing and post-event debriefing indicators.

Consent provided by a legally authorised person on behalf of a patient who lacks decision-making capacity. The authorised person varies by jurisdiction: 'person responsible' (NSW), 'medical treatment decision maker' (Vic), 'guardian' (various), or a guardian appointed by a tribunal. The substitute decision maker must make the decision the patient would have made, based on the patient's known values and preferences where possible.

A deliberate pause immediately before a procedure begins, during which the clinical team confirms: correct patient, correct procedure, correct site, correct laterality (if applicable), correct consent, and that required equipment and imaging are available. Derived from the WHO Surgical Safety Checklist but applicable to any procedural setting, including minor procedures in specialist rooms.

The open licence under which the SPQF is published. It means you are free to copy, share, and adapt the framework for any purpose (including commercial use), as long as you give appropriate credit. You do not need permission to use the framework in your practice.

The second of four maturity levels in the SPQF. An indicator rated Developing means the practice does this inconsistently, informally, or partially. There may be a process that some staff follow, but it is not documented, not reliable, or not applied consistently. The practice has recognised the gap and may have started working on it.

One of eight broad areas of practice quality covered by the SPQF. Each domain contains multiple quality statements, and each quality statement contains multiple indicators. The eight domains are: (1) Clinical Governance and Leadership, (2) Patient Safety and Risk Management, (3) Clinical Effectiveness, (4) Patient Experience and Engagement, (5) Information Governance and Health Records, (6) Workforce and Team Capability, (7) Practice Environment and Infrastructure, and (8) Continuous Improvement.

The third of four maturity levels in the SPQF. An indicator rated Established means the practice does this reliably and could demonstrate it to a third party if asked. A documented process exists, staff are aware of it, and it is followed consistently. This is the target level for most indicators.

The fourth and highest maturity level in the SPQF. An indicator rated Excelling means the practice not only does this reliably but actively reviews and improves it over time, informed by data or feedback. Not expected for every indicator — reflects areas where a practice has chosen to invest additional effort.

A specific, observable measure that sits underneath a quality statement. Indicators describe concrete actions, processes, or evidence you would expect to see in a practice that meets the quality statement. The SPQF contains 369 indicators across eight domains. Each indicator is assessed against the four maturity levels.

The four-point scale used in the SPQF to rate each indicator: Not in Place, Developing, Established, and Excelling. The scale describes where your practice is now — it is descriptive, not judgmental. 'Established' is the target for most indicators. 'Not in Place' is a valid starting point, not a failure.

The first of four maturity levels in the SPQF. An indicator rated Not in Place means the practice does not do this, or is unaware of the requirement. It is not a failure — it is an honest description of where you are starting from, and it tells you exactly what needs to be addressed.

A high-level commitment that describes what good looks like in a particular area of practice. Each domain contains five to seven quality statements. Indicators sit underneath quality statements and provide the specific, measurable criteria. Quality statements are aspirational but achievable — they describe the standard a well-run practice should meet.

The quality framework you are using. A voluntary, self-assessed framework designed for specialist medical practices in Australia. Covers eight domains: clinical governance and leadership, patient safety and risk management, clinical effectiveness, patient experience and engagement, information governance and health records, workforce and team capability, practice environment and infrastructure, and continuous improvement. Published under CC-BY 4.0.

The process of evaluating your own practice against the SPQF indicators, recording your maturity level for each, and identifying priorities for improvement. Self-assessment means you assess yourself — nobody external reviews your ratings. The value is in the honest reflection and the actions that follow, not in achieving a particular score.

A documented plan that describes how your practice would continue to operate (or safely wind down) during a major disruption — such as fire, flood, IT failure, pandemic, or the incapacity of the principal practitioner. Does not need to be elaborate. A two to four page document covering the most likely scenarios is adequate for most specialist practices.

The process of verifying that a practitioner holds the qualifications, registration, insurance, and other credentials necessary to provide the services they will deliver at your practice. In the SPQF context, credentialing means checking and documenting — not the hospital-style credentialing and scope of practice committee process. At minimum: verify AHPRA registration, college fellowship, and professional indemnity insurance, and keep copies on file.

A file (physical folder or digital equivalent) maintained for each practitioner containing verified copies of their registration, qualifications, fellowship, insurance, any conditions or undertakings, and a log of verification checks. The single most commonly missing piece of evidence in specialist practice governance.

A documented statement specifying who has the authority to make particular decisions on behalf of the practice — such as approving expenditure, signing contracts, authorising leave, or committing to service agreements. Without delegations, the practice manager either acts without authority (creating risk) or cannot act at all (creating paralysis).

An organisational culture that distinguishes between human error (which is managed through system improvement, not punishment), at-risk behaviour (which is managed through coaching and removing incentives for the behaviour), and reckless behaviour (which is managed through disciplinary action). In a just culture, staff feel safe to report incidents and near-misses because the default response is learning, not blame. Does not mean no accountability — it means accountability is proportionate and fair.

A simple quality improvement cycle: Plan what you want to change and how you will measure it, Do the change on a small scale, Study the results to see if the change worked, Act on what you learned (adopt, adapt, or abandon). The most practical QI methodology for specialist practice because it is small-scale, iterative, and does not require statistical expertise.

The senior clinician who holds overall accountability for clinical governance in the practice. In a solo practice, this is the specialist. In a multi-practitioner group, it is the designated clinical lead — often (but not necessarily) the most senior partner or the practice owner. The SPQF does not prescribe a governance structure but requires that someone is clearly identified as clinically accountable.

A structured document (usually a spreadsheet) that lists the risks facing your practice, along with their assessed likelihood and consequence, current controls, and any actions planned to reduce the risk further. Each risk should have a nominated owner. A well-maintained risk register is one of the most useful governance tools a practice can have — and one of the most commonly missing.

The range of clinical services that a practitioner is qualified, competent, and authorised to provide. In the SPQF context, this applies at two levels: the individual practitioner's scope (determined by their registration, training, and competence) and the practice's scope (the range of services the practice is set up and equipped to offer). The two should align — a practitioner should not be performing services the practice is not equipped to support.

The national standard that specifies requirements for cleaning, disinfecting, and sterilising reusable medical instruments. If your practice reprocesses instruments (rather than using only single-use items), this standard governs how you must do it. Covers everything from instrument transport through cleaning, packaging, sterilisation, storage, and traceability.

A method of testing surface cleanliness by detecting biological residue. A swab is taken from a surface and a luminometer gives a reading indicating the level of organic contamination. Used in some practices as an objective measure of cleaning effectiveness.

A test containing bacterial spores (typically Geobacillus stearothermophilus for steam sterilisation) used to verify that a sterilisation cycle achieved conditions sufficient to kill microorganisms. Run at least weekly in your autoclave. If a biological indicator fails, all instruments processed since the last successful test must be recalled or quarantined.

A device that changes colour when exposed to one or more sterilisation parameters (e.g., temperature, time, steam). Placed inside every sterilisation load to provide immediate visible confirmation that conditions were reached. Chemical indicators do not confirm sterility — they confirm that physical conditions were met. Biological indicators are needed to confirm microbial kill.

The WHO framework identifying five critical points during patient care when hand hygiene must be performed: (1) before touching a patient, (2) before a clean or aseptic procedure, (3) after body fluid exposure risk, (4) after touching a patient, and (5) after touching patient surroundings. The foundation of standard precautions in any clinical setting.

A method of auditing environmental cleaning. Invisible fluorescent marks are applied to surfaces before cleaning, then checked with a UV light after cleaning. If the marks remain, the surface was not adequately cleaned. A simple, inexpensive audit tool for verifying cleaning compliance.

Equipment worn by staff to protect against exposure to infectious agents or hazardous substances. In specialist practice, PPE typically includes gloves, masks (surgical and P2/N95), eye protection (goggles or face shields), and gowns. The type of PPE required depends on the task and level of risk.

The minimum infection prevention practices that apply to all patient care, regardless of the patient's suspected or confirmed infection status. Based on the principle that all blood, body fluids, non-intact skin, and mucous membranes may contain transmissible infectious agents. Includes hand hygiene, PPE, safe handling of sharps, respiratory hygiene, environmental cleaning, and waste management.

In the context of instrument reprocessing, traceability is the ability to link a specific sterilised instrument (or instrument set) to: the patient it was used on, the sterilisation cycle that processed it, and the monitoring results for that cycle. Enables patient recall if a sterilisation failure is identified retrospectively. Can be achieved with a paper-based logbook or an electronic tracking system.

An independent, evidence-based prescribing reference widely used in Australian clinical practice. Available in print and online. One of several acceptable prescribing references (alongside MIMS and eTG).

The system of transporting and storing temperature-sensitive products (particularly vaccines and some biologics) within the required temperature range (typically 2–8°C) from manufacturer to patient. A break in the cold chain can render medications ineffective or unsafe. Requires a purpose-built vaccine refrigerator (not a domestic bar fridge), continuous or twice-daily temperature monitoring, and a documented breach procedure.

Medications listed in Schedule 8 of the Standard for the Uniform Scheduling of Medicines and Poisons — drugs of addiction including opioids (morphine, oxycodone, fentanyl), benzodiazepines, and stimulants. Subject to strict storage (locked safe), recording (controlled drugs register), and regulatory requirements that vary by state and territory.

A safety checklist applied before administering any medication: right patient, right drug, right dose, right route, right time. A minimum standard — some frameworks add right documentation, right reason, and right response as additional checks.

A prescribing reference providing product information for medications available in Australia. Available in print and online. One of several acceptable prescribing references alongside AMH and eTG.

The Australian Government program that subsidises the cost of medicines for patients. Practitioners prescribing PBS medicines must comply with PBS prescribing rules, including obtaining authority approvals where required. Relevant to prescribing compliance indicators.

The category in the Standard for the Uniform Scheduling of Medicines and Poisons that covers controlled drugs — drugs of addiction. See 'Controlled drugs' for full definition.

An Australian evidence-based clinical decision support resource providing prescribing and treatment guidelines across multiple therapeutic areas. Available by subscription. One of several acceptable prescribing references alongside AMH and MIMS.

A term used in Australian healthcare to describe patients and communities whose cultural background, language, or ethnicity differs from the majority English-speaking population. Relevant to the framework in the context of interpreting services, translated materials, and culturally appropriate care.

A national interpreting service provided by the Australian Government. Available 24/7 for telephone interpreting in over 150 languages. Medical practitioners can access TIS National free of charge for private consultations with non-English speaking patients through the Free Interpreting Service. Call 131 450.

The 13 principles set out in the Privacy Act 1988 that govern how organisations collect, use, store, and disclose personal information. They apply to most specialist practices (those with annual turnover above $3 million, or that provide a health service). APP 3 covers collection, APP 6 covers use and disclosure, APP 11 covers security, and APP 12 covers access.

A security method requiring two or more forms of verification to access a system — typically something you know (password) plus something you have (phone, token) or something you are (fingerprint). Recommended for all clinical systems, particularly cloud-based practice management software and remote access.

Australia's national digital health record system. An opt-out system where every Australian has a record unless they have chosen to cancel it. Practitioners can upload clinical documents, prescriptions, and discharge summaries. Relevant to medication safety (shared prescribing information visible to all treating practitioners) and patient access to information.

A scheme under the Privacy Act 1988 requiring organisations to notify the OAIC and affected individuals when a data breach is likely to result in serious harm. A data breach occurs when personal information is accessed, disclosed, or lost without authorisation. Common examples in specialist practice: ransomware attack on practice systems, misdirected fax containing patient records, lost or stolen laptop with unencrypted patient data.

The primary Commonwealth legislation governing the handling of personal information in Australia. Contains the Australian Privacy Principles (APPs). Applies to most specialist practices. Supplemented by state and territory health records legislation in some jurisdictions.

The national body responsible for registering health practitioners and managing notifications (complaints) about their conduct, health, or performance. Every practitioner working in your practice must hold current AHPRA registration. The AHPRA public register is free to search online and is the primary tool for verifying practitioner credentials.

The independent body that receives and investigates complaints about health service providers in New South Wales. Equivalent bodies exist in other states and territories: Health Ombudsman (Qld), Health Complaints Commissioner (Vic), and similar offices in each jurisdiction. Patients should be informed they can complain to the relevant body if they are not satisfied with the practice's internal complaints process.

The independent body that manages health complaints in Queensland. Equivalent to the HCCC in NSW and similar bodies in other jurisdictions. The specific body relevant to your practice depends on your state or territory.

A legal obligation under the Health Practitioner Regulation National Law for certain people (including employers and fellow practitioners) to notify AHPRA when they reasonably believe a registered practitioner has behaved in a way that constitutes notifiable conduct: practising while intoxicated by alcohol or drugs, sexual misconduct in the practice of the profession, placing the public at substantial risk of harm due to a significant departure from accepted professional standards, or having an impairment that places the public at substantial risk of harm. The threshold is high but the obligation is non-discretionary — once the threshold is met, you must notify.

The legislation underpinning the national registration and accreditation scheme for health practitioners in Australia. Establishes AHPRA, the National Boards, and the framework for registration, notifications, and mandatory reporting. Referenced in the SPQF primarily in relation to mandatory notification obligations and practitioner conduct.

The federal body responsible for privacy regulation under the Privacy Act 1988. The OAIC oversees compliance with the Australian Privacy Principles, receives and investigates privacy complaints, and administers the Notifiable Data Breaches scheme. If a patient believes their privacy has been breached, the OAIC is where they can complain (after attempting to resolve it with the practice first).

A scheme established under the Health Insurance Act 1973 to review practitioners whose billing patterns suggest they may be providing inappropriate or excessive services. PSR can investigate individual practitioners and impose sanctions including repayment of Medicare benefits, counselling, and disqualification from Medicare for up to three years.

Ongoing learning and development activities that practitioners undertake to maintain and extend their professional competence. All AHPRA-registered practitioners are required to meet CPD standards set by their National Board. Specialist colleges also set CPD requirements for fellows.

A structured evaluation of whether a staff member can perform a specific task safely and correctly. Differs from training (which provides knowledge and skills) — competency assessment verifies that the person can apply what they have learned in practice. Should be conducted at onboarding and periodically for critical tasks.

A confidential support service for doctors and medical students experiencing health issues, including mental health concerns, substance use, and burnout. Operated independently in each state and territory. Provides telephone support, face-to-face appointments, and referrals. Free and confidential. The practice should make this service known to all medical practitioners.

A confidential counselling and support service provided by an employer for staff experiencing personal or work-related difficulties. Larger practices may contract an EAP provider. Smaller practices that cannot afford a dedicated EAP can point staff to free services such as the Doctors' Health Advisory Service, Nurse & Midwife Support, or Beyond Blue.

A national 24/7 confidential support service for nurses and midwives experiencing personal or work-related difficulties. Provides telephone counselling, referral, and information. Free service funded by the Australian Government. Phone 1800 667 877.

A document that defines a role within the practice: its title, purpose, key responsibilities, reporting line, qualifications or competencies required, and conditions of employment. Not the same as an employment contract (which is a legal agreement). A position description should exist for every distinct role, and should be reviewed when the role changes or during annual performance reviews.

A screening process required in most Australian jurisdictions for people who work with or care for children. The specific name and requirements vary by state and territory (e.g., Working With Children Check in NSW and Vic, Blue Card in Qld, WWVP in SA). Required for staff in specialist practices that see paediatric patients. Must be obtained before the person commences in the role.

A document that provides detailed information about a hazardous chemical: what it is, its hazards, how to handle and store it safely, first aid measures, spill procedures, and disposal requirements. Under WHS legislation, an SDS must be available for every hazardous chemical used in the workplace. Must be current (within five years) and accessible where the chemical is used.

The body of law, regulation, and practice aimed at protecting the health, safety, and welfare of people at work. In most Australian jurisdictions, WHS legislation imposes duties on 'persons conducting a business or undertaking' (PCBUs) — which includes specialist practices — to ensure, so far as is reasonably practicable, the health and safety of workers and others in the workplace. Covers physical hazards, chemical hazards, biological hazards, ergonomics, and psychosocial hazards (including workplace bullying).