Governance & Staffing

MANDATORY

5 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [31] Continuity of care functions as genuine infrastructure protecting both patient outcomes and the rural primary care workforce itself, establishing defined coverage arrangements, distinct from unplanned care gaps, as essential to sustaining this infrastructure specifically in solo and small rural practice.

Continuity of care, the entire foundation this document is built around, has a real, specific vulnerability in a genuine solo practice that a larger team doesn't face in the same way — when the one doctor is unavailable, without a defined coverage plan, every patient's continuity simply stops, at exactly the moment it might matter most.

1 A coverage plan exists for planned absences but not genuinely for sudden, unplanned unavailability.

A genuine emergency doesn't announce itself in advance, and the plan needs to cover this reality too.

2 An alternative provider is named but the relationship hasn't been recently reconfirmed as still active.

A coverage relationship needs to remain genuinely active, not just historically established.

3 The plan exists but patient awareness relies on them happening to ask, not proactive communication.

Genuine, proactive awareness is more reliable than a plan patients only discover by chance.

Week 1 Review current coverage arrangements for genuine readiness, including sudden, unplanned absence.

Week 2 Establish or reconfirm a specific, named alternative provider relationship.

Week 3 Build proactive patient communication about the coverage plan.

Ongoing Periodically reconfirm the coverage relationship remains genuinely active.

Ask what specifically would happen if the doctor became suddenly, unexpectedly unavailable today.

A specific, confident answer reveals a genuine plan, not an assumption it would work out.

Ask a patient directly whether they know what to do if the doctor were unavailable.

This tests genuine, proactive awareness, not an assumption patients would figure it out.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [32] Agency for Healthcare Research and Quality research found that more than one quarter of physicians in small- and medium-sized primary care practices experience moderate to severe burnout, with rural clinicians reporting the highest rates, and established that burnout measurably impairs attention, memory, and executive function with direct implications for patient safety.

Research specifically shows rural and small-practice clinicians experience the highest rates of burnout among primary care providers, and burnout isn't only a wellbeing concern — it measurably impairs attention, memory, and executive function, meaning a burned-out physician represents genuine, real patient safety risk, not simply a private struggle with no bearing on care quality.

1 Attention to wellbeing happens informally but isn't structured into any genuine, regular process.

Informal attention is less reliable than a genuine, structured practice that doesn't depend on someone happening to notice.

2 Support resources exist but are genuinely difficult to access given the demands of solo practice.

A resource that's difficult to actually use in practice provides limited real protective value.

3 Workload review happens but doesn't lead to genuine adjustment even when sustainability concerns are identified.

A review without real, resulting action doesn't provide the genuine protection this criterion exists to ensure.

Week 1 Review current attention to physician wellbeing for genuine structure versus informal assumption.

Week 2 Establish genuine, accessible support specifically feasible for solo practice demands.

Week 3 Build a periodic, structured workload sustainability review.

Ongoing Act on genuine sustainability concerns identified through review.

Ask the physician directly about their own current workload sustainability and access to support.

A genuine, honest answer reveals real practice, not an assumption everything is fine.

Ask what specifically changed the last time a wellbeing or workload concern was identified.

A real, specific example reveals whether attention leads to genuine action, not just awareness.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [33] Quality improvement initiatives adapted for solo and small primary care practices, including structured support models and micro-scale improvement projects, are established as genuinely effective and appropriate to practice size, distinct from an assumption that meaningful quality improvement requires large-scale infrastructure.

Quality improvement doesn't require a large committee to be genuine — even a solo practitioner can identify a specific, real quality gap and work through a structured improvement cycle, and the absence of this genuine practice, not the absence of formal infrastructure, is what actually represents a real gap in this standard.

1 An improvement effort was started but hasn't been genuinely completed or evaluated.

A genuine improvement cycle needs to reach evaluation to demonstrate real, meaningful effect.

2 The chosen focus is reasonable but wasn't specifically selected based on this practice's own real data or experience.

Genuine relevance comes from grounding the effort in this practice's actual circumstances, not a generic priority.

3 A change was made but wasn't genuinely measured to confirm it produced real improvement.

An unmeasured change is difficult to distinguish from a change that didn't actually help.

Week 1 Identify a real, specific quality gap genuinely relevant to this practice.

Week 2 Design a small, appropriately scaled improvement effort addressing this gap.

Week 3 Implement the improvement and establish a way to genuinely measure its effect.

Ongoing Evaluate the improvement effort and identify the next genuine priority.

Ask what specific quality gap the current improvement effort is genuinely addressing.

A specific, real answer reveals genuine relevance, not a generic exercise.

Ask for real evidence the improvement effort actually changed something measurable.

A specific, real outcome reveals genuine effect, not activity alone.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [34] Structured training and competency verification, distinct from informal on-the-job learning alone, is established practice for genuine patient safety regardless of practice size, with quality improvement support models specifically developed to extend structured training support to small and solo practices.

A practice with very few staff can genuinely underinvest in structured training precisely because informal, on-the-job learning feels sufficient for a small team — but the real risk a specific task carries doesn't diminish just because the practice is small, and every staff member's actual competency deserves the same genuine verification regardless of team size.

1 Training is documented for clinical tasks but less structured for administrative or support roles.

Every role, including administrative ones, carries real responsibilities that benefit from genuine, structured training.

2 Initial training is thorough but ongoing refresher training is inconsistent.

Skills and knowledge benefit from genuine, periodic reinforcement, not a single strong initial session alone.

3 Training happens but competency verification relies on informal observation rather than a genuine, structured check.

A structured verification process is more reliable than informal impression alone.

Week 1 Review current staff training for genuine structure versus informal on-the-job learning.

Week 2 Build structured, documented training for every staff role, including administrative.

Week 3 Establish genuine competency verification, not assumed from tenure.

Ongoing Refresh training periodically for all staff.

Ask to see the actual, documented training record for a specific staff member.

A specific, real record reveals genuine structure, not informal learning assumed sufficient.

Ask an administrative or support staff member about their own specific training.

This reveals whether structured training genuinely extends beyond clinical roles.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [35] Genuine review and resulting practice change following an incident, distinct from documentation alone, is established as essential to meaningful quality improvement and patient safety learning in primary care, regardless of practice size or formal committee structure.

An incident report that exists only as documentation, without genuine reflection on why it happened and what should change, provides none of the real protective value incident reporting is meant to offer — the whole point is learning from what actually happened, not simply creating a record that it did.

1 Review happens for significant incidents but not consistently for smaller, less dramatic ones.

Smaller incidents can still reveal genuine, real patterns worth understanding.

2 Review is thorough but resulting changes aren't consistently tracked to confirm they were actually implemented.

An identified change that isn't tracked to genuine implementation may not actually happen.

3 Near-misses are occasionally reviewed but not as a genuine, consistent practice.

Consistent review of near-misses provides earlier, more reliable learning than occasional attention alone.

Week 1 Review current incident handling for genuine reflection versus documentation alone.

Week 2 Establish a genuine review process covering both actual incidents and near-misses.

Week 3 Build tracking to confirm identified changes are genuinely implemented.

Ongoing Review incident and near-miss patterns periodically for genuine learning.

Ask for a real, specific example of an incident review and what actually changed as a result.

A real, traceable example reveals genuine learning, not documentation alone.

Ask about a recent near-miss and how it was genuinely reviewed.

This reveals whether near-misses receive real attention, not only events that caused actual harm.