POLICY: Standards for Primary Care

PREAMBLE

The College of Physicians and Surgeons of Saskatchewan (College) has responsibility to set standards and policies that result in high quality care for patients regardless of their point of contact with physicians in the health care system.

The Code of Ethics and Professionalism of the Canadian Medical Association establishes expectations for physicians which include expectations that physicians will provide appropriate care to their patients, whatever practice setting they may work in. The Code of Ethics and Professionalism and the Code of Conduct, part of the College’s regulatory bylaws, are the foundation for this document.

Commitment to the well-being of the patient

Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient.

Provide appropriate care and management across the care continuum.

Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm has occurred.

Recognize the balance of potential benefits and harms associated with any medical act; act to bring about a positive balance of benefits over harms.

Physician-patient relationship

2.    Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted; until another suitable physician has assumed responsibility for the patient or until the patient has been given reasonable notice that you intend to terminate the relationship.

The CPSS expects that physicians will:

1. a. Ensure patient care and safety assume the highest priority in the clinical setting. The duty of physicians to advocate for patients does not excuse or justify unacceptable behavior; it must be done constructively.
2. b. Provide the medical follow-up required by a patient’s condition after undertaking an examination, investigation or treatment of a patient unless the physician has ensured that another physician, another professional or another authorized person has agreed to do so.

DEFINITION

In this document the College adopts the definition of “chronic disease” from World Health Organization “diseases of long duration and generally slow progression.”

Examples of chronic diseases are the following (but not limited to):

• Diabetes
• Hypertension
• Asthma
• COPD
• Mood disorders
• Hyperlipidemia
• Congestive cardiac failure
• Chronic Renal Failure
• Chronic Pain
• Coronary Artery Disease
• Seizure Disorders
• Thyroid Disease

THE STANDARD

The College expects that appropriate care will be provided to all patients, in whatever practice setting that care is provided.

This standard applies to all physicians providing primary care in all practice settings, including walk-in clinics, family practice clinics, primary health care clinics and minor emergency clinics.

Physicians who provide primary care will:

1. 1) Ensure that any practice location in which they work has appropriate systems in place to review and, if appropriate, provide follow-up care in response to any investigations ordered by the physician. When possible, the results of such investigations should be reviewed by the physician who has ordered the investigations and, when not possible, investigations results will be reviewed by a qualified medical colleague;

    

2. 2) Ensure that any practice location in which they work has appropriate systems in place to review and, if appropriate, provide follow-up care in response to consultant’s reports requested by the physician. When possible, consultant’s reports should be reviewed by the physician who requested the consultation and, when not possible, such reports will be reviewed by a qualified medical colleague;

    

3. 3) Ensure that any practice location in which they work has appropriate systems in place to contact a patient when follow - up care is necessary and to document all contacts and attempts to contact the patient;

    

4. 4) Ensure that any practice location in which they work has appropriate systems in place to respond to “critical” diagnostic test results reported by a laboratory or imaging facility for urgent attention after regular working hours or in the absence of the ordering physician;
5. 5) Remain responsible for any follow-up care required as a result of any investigations ordered or consultations requested by the physician unless another physician has accepted the responsibility to provide the follow-up care.

    

6. 6) Ensure that any practice location in which they work has appropriate systems in place to comply with the policy of the College on Medical Practice Coverage which states “All physicians involved in direct patient care have an obligation to arrange for 24-hour coverage of patients currently under their care.”

    

7. 7) With respect to each patient encounter:

1. a. Obtain and document a history appropriate to the patient’s presenting concerns,
2. b. Collect information about relevant past medical history, drug reactions, current medication, allergies and active health problems;
3. c. Discuss and document:
   1. i. diagnoses reached,
   2. ii. investigations ordered,
   3. iii. treatment and advice given,
   4. iv. procedures performed,
   5. v. referrals made, and
   6. vi. follow-up planned
4. d. Observe, examine and document relevant physical findings both positive and negative;
5. e. Assess the patient to determine if the investigation of the patient’s medical condition should include ordering laboratory tests, diagnostic imaging, a referral to a consultant or other investigatory methods;
6. f. If the physician intends to only provide episodic care to the patient, to so advise the patient and encourage the patient to establish a patient/doctor relationship with a family physician. The physician will advise the patient of the value of such a continuing care arrangement. The establishment of such a care arrangement should be facilitated if possible, either within the clinic or with another physician or clinic;

8)    Physicians are not required to address all patients concerns in one visit, but must place the patient’s best interest before his/her own and implement practices to ensure that urgent matters are appropriately addressed in a timely fashion, and less urgent matters are deferred to a later scheduled appointment.

9) Physicians who establish a process for dealing with circumstances where a patient presents with multiple concerns must establish a process which accords with the responsibility of the member:

1. a. to gather sufficient information from the patient to triage patient concerns;
2. b. to decide which concerns must be dealt with at that visit and which concerns can safely wait; and
3. c. to schedule appointment(s) to address concerns not dealt with, within a time frame appropriate for the condition.

10) Physicians must not have office policies or office signage which attempt to limit a patient to discussing one problem in one patient visit, as they do not accord with the member’s responsibility to triage when multiple concerns are presented.

11) Physicians are encouraged to make information available to their patients related to their approach to dealing with patients who present with multiple concerns.

12) If the physician does not intend to provide comprehensive care to a patient who is not a regular patient of the Clinic, and who has attended the clinic for management of a chronic disease, the physician will assess whether appropriate medical care requires that investigations should be ordered or a referral to a consultant be made. The physician will:

1. a. if the patient has a family physician:
   1. i. advise the patient to arrange any non-urgent consultations through the patient’s family physician; or
   2. ii. unless the patient is non-compliant with the physician’s recommendations, arrange any urgent consultations with an appropriate consultant and, when doing so, advise the consultant of the patient’s family physician so the consultant will keep that family physician informed and involved in the patient's ongoing care.
2. b. if the patient does not have a family physician, the physician will provide standardized care for the specific chronic condition and instruct the patient to find a family physician;
3. c. document the discussion with the patient and, if the patient is not compliant with the physician’s recommendations, document that fact.

13)    If the physician intends to only provide episodic care to a patient, ensure that the clinic is compliant with the College policy Clinics That Provide Care To Patients Who Are Not Regular Patients Of The Clinic .