ASF Standards · Primary Health Clinic · Standard 7
Standard 7 — Governance & Staffing
Criteria in this standard
7.1 — A Defined Coverage Plan Exists for When the Solo Doctor Is Unavailable
7.2 — Physician Wellbeing Is Actively Monitored and Supported, Not Left to Individual Resilience Alone
7.3 — A Genuine Quality Improvement Process Exists, Even at Small Scale
7.4 — Staff, However Few, Receive Real, Documented Training for Their Actual Role
7.5 — Incident Reporting Leads to Genuine Learning, Not Just Documentation
7.2 — Physician Wellbeing Is Actively Monitored and Supported, Not Left to Individual Resilience Alone
7.3 — A Genuine Quality Improvement Process Exists, Even at Small Scale
7.4 — Staff, However Few, Receive Real, Documented Training for Their Actual Role
7.5 — Incident Reporting Leads to Genuine Learning, Not Just Documentation
7.1
A Defined Coverage Plan Exists for When the Solo Doctor Is Unavailable
Non-Negotiable
A genuine, defined coverage arrangement exists for when the practice's own doctor is unavailable — illness, leave, emergency — with a real, named alternative for patients needing care in that gap, not an assumption that patients will simply wait or seek care elsewhere on their own.
In plain terms: When the practice's doctor is away — sick, on leave, at a funeral — there is a written arrangement for who covers, and patients know how to reach care.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
A solo practice with no cover is a practice that closes when the doctor is ill. Patients with acute needs go to the emergency department; patients with chronic needs run out of medication; results go unreviewed; referrals stall. A coverage plan names who covers (a neighbouring practice, a locum agency, a colleague), what they cover (acute visits, prescriptions, results), how patients are told (a recorded message, a notice, a text), and how the covering clinician accesses the records. It is written before it is needed and tested annually.
What good looks like
- A genuine, defined coverage arrangement exists and is real, not theoretical.
- A specific, named alternative provider is identified for coverage gaps.
- Patients are genuinely, proactively aware of the coverage plan.
Common failure modes
- No defined coverage arrangement exists beyond an assumption patients will manage.
- No specific alternative is identified; patients are vaguely told to seek care elsewhere.
- Patients only learn about coverage gaps when they actually encounter one.
Worked example
In practice
A single-doctor health centre with two nurses and 2,500 patients.
BeforeWhen the doctor was hospitalised for a week, the practice closed. Patients arrived to a locked door. Prescriptions ran out. Abnormal results sat unreviewed. The nurses had no authority to act and no one to call.
ActionA reciprocal coverage agreement was signed with a neighbouring practice: each covers the other's acute visits, prescriptions, and result review during absence. Records access was arranged. A written absence protocol names who activates cover, what message goes on the phone and door, and how the nurses escalate. The arrangement was tested with a one-day planned absence.
AfterThe Monitor reviewed the signed agreement, the absence protocol, the records access arrangement, and the test-day record. Verified.
If you are starting from zero — do this first
- Ask: what happened last time the doctor was unexpectedly away?
- Find a neighbouring practice and propose reciprocal cover.
- Write a one-page absence protocol: who activates, what message, how to escalate.
- Test it with a planned absence.
The most common mistake: Assuming a solo doctor will never be unavailable — everyone is unavailable eventually.
Self-assessment questions
1. Does a genuine, defined coverage arrangement exist for when the doctor is unavailable? — A real, specific arrangement, not an assumption that patients will manage without care.
Evidence: Coverage arrangement documentation
Evidence: Coverage arrangement documentation
2. Is there a real, named alternative provider or facility patients can be directed to during a coverage gap? — A specific, real alternative, not a vague suggestion to seek care elsewhere.
Evidence: Named alternative provider documentation
Evidence: Named alternative provider documentation
3. Are patients genuinely informed of the coverage plan, not left to discover it only when they need it? — Real, proactive patient awareness, not information they only encounter during an actual gap.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- 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.
- 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.
- The plan exists but patient awareness relies on them happening to ask, not proactive communication.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Coverage plan review | Reviews the actual, defined coverage arrangement for when the doctor is unavailable. |
| DOCUMENT | Alternative provider review | Reviews the specific, named alternative provider or facility patients would be directed to. |
| ASK | Patient awareness interview | Asks a patient whether they know what to do if the practice's doctor were unavailable. |
Supervisor tips
- 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.
Evidence base
[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.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
7.2
Physician Wellbeing Is Actively Monitored and Supported, Not Left to Individual Resilience Alone
Non-Negotiable
The physician's own wellbeing and burnout risk is genuinely, actively monitored and supported — real access to support, genuine attention to sustainable workload — not treated as a private matter left entirely to individual resilience with no structural attention at all.
In plain terms: The doctor's own wellbeing and burnout risk are monitored and supported — real access to help, real time off, real workload limits — not left to 'they'll cope.'
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
A burned-out doctor makes more errors, retires earlier, and — in the worst cases — harms themselves. Primary care burnout is epidemic and structural: workload, isolation, administrative load, the impossibility of doing everything. A practice that treats physician wellbeing as a personal matter loses its doctor eventually. Monitoring means a regular check-in — a validated burnout measure annually, a conversation with a peer or mentor, workload data reviewed; support means protected time, access to confidential counselling, administrative help, and a culture where saying 'I am struggling' is safe. In a solo practice, this may mean an external peer group.
What good looks like
- Physician wellbeing receives genuine, active attention, not treated as purely private.
- Real, accessible support exists if burnout risk is identified.
- Workload is genuinely, periodically reviewed for sustainability.
Common failure modes
- Wellbeing is treated as an entirely private matter with no structural attention.
- No genuine, accessible support exists beyond a theoretical resource.
- Workload sustainability is assumed, never genuinely reviewed.
Worked example
In practice
A single-doctor health centre where the doctor worked 60-hour weeks and had not taken leave in two years.
BeforeNobody asked how the doctor was. He had not taken leave because there was no cover. He was making documentation errors and had become short with patients. Two complaints in three months. He did not recognise it as burnout; the practice manager did but did not know how to raise it.
ActionWith the coverage arrangement (7.1) in place, four weeks of leave were scheduled. A validated burnout measure (Maslach or a brief equivalent) is completed annually and reviewed with a trusted peer from the reciprocal practice. A monthly peer group of four local solo doctors was joined. Administrative tasks were delegated to the practice manager. A confidential counselling service was identified. Workload data — consultations per day, hours worked — is reviewed quarterly.
AfterThe Monitor reviewed the burnout measure results (improved over two years), leave records, peer group attendance, and delegated task list. Interviewed the practice manager who described the check-in process. Verified.
If you are starting from zero — do this first
- When did the doctor last take two consecutive weeks off?
- Complete a validated burnout measure this month.
- Find or form a peer group.
- Delegate three administrative tasks this month.
The most common mistake: Treating the doctor's wellbeing as the doctor's own business — a burned-out doctor is the practice's biggest risk.
Self-assessment questions
1. Is physician wellbeing genuinely, actively monitored, not treated as a purely private matter? — Real, active attention, not an assumption that wellbeing is solely the individual's own concern.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
2. Does the physician have genuine, real access to support if burnout risk is identified? — Actual, accessible support, not a theoretical resource that's difficult to genuinely use.
Evidence: Support access documentation
Evidence: Support access documentation
3. Is workload genuinely, periodically reviewed for sustainability, not assumed manageable indefinitely? — Real, periodic review, not an assumption the current pace is sustainable without ever checking.
Evidence: Workload review record
Evidence: Workload review record
Common reasons for a PARTIAL answer
- 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.
- 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.
- Workload review happens but doesn't lead to genuine adjustment even when sustainability concerns are identified.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| ASK | Wellbeing monitoring interview | Asks the physician directly whether their own wellbeing receives genuine, active attention. |
| DOCUMENT | Support access review | Reviews what genuine, accessible support exists if burnout risk is identified. |
| DOCUMENT | Workload review documentation | Reviews evidence of periodic, genuine workload sustainability review. |
Supervisor tips
- 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.
Evidence base
[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.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
7.3
A Genuine Quality Improvement Process Exists, Even at Small Scale
Core
The practice maintains a genuine, ongoing quality improvement process — even a small, single, well-chosen project — not the absence of any structured improvement effort simply because the practice is too small for a formal committee structure.
In plain terms: The practice has an ongoing quality improvement process — even one small, well-chosen project at a time — not the assumption that small practices are too small for QI.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Adapted | Full |
Why this matters
'We're too small for quality improvement' is the most common excuse in primary care and the least valid. QI at small scale is one project: pick a measure (e.g. proportion of diabetics with an annual foot check), find the baseline (20%), make a change (nurse does foot checks at every diabetes visit), remeasure (75%), keep it going. That is the whole method. One project at a time, completed, documented, sustained, then the next. A practice that has done three such projects in two years has a QI process. A practice waiting until it is big enough will wait forever.
What good looks like
- A genuine, ongoing improvement effort exists, appropriately scaled to the practice.
- The effort addresses a real, specific gap identified in this practice.
- Real evidence shows a genuine, measurable resulting change.
Common failure modes
- No genuine improvement effort exists, treated as unnecessary given small practice size.
- Any improvement activity is generic, not genuinely relevant to this practice's real circumstances.
- No evidence connects improvement activity to any genuine, measurable change.
Worked example
In practice
A single-doctor health centre with no history of quality improvement.
BeforeThe doctor believed QI was for large organisations. No measure had ever been tracked. No improvement project had been attempted. The practice was not getting better.
ActionOne project was chosen: increase influenza vaccination in over-65s. Baseline measured (28%). Change: nurse recall list and phone calls in October. Remeasured in January (58%). Documented on one page. Second project: reduce missed specialist referrals, using the referral log (5.1). Third: hand hygiene. Each project is one page: measure, baseline, change, result.
AfterThe Monitor reviewed three completed one-page QI projects with baseline and result data, and the plan for the fourth. Verified.
If you are starting from zero — do this first
- Choose one thing to improve. Just one.
- Measure it now — that is your baseline.
- Make one change.
- Measure again in three months. Write it on one page.
The most common mistake: Waiting to be big enough for QI — one project on one page is QI.
Self-assessment questions
1. Does the practice maintain a genuine, ongoing quality improvement effort, even at small scale? — A real, specific improvement effort, not the absence of one justified by practice size.
Evidence: Quality improvement project documentation
Evidence: Quality improvement project documentation
2. Is the improvement effort based on a real, identified gap specific to this practice, not a generic exercise? — Genuine, specific relevance to this practice's actual circumstances, not a generic template.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
3. Is there real evidence the improvement effort has produced a genuine, measurable change? — Actual, measurable outcome, not activity without demonstrated real effect.
Evidence: Improvement outcome evidence
Evidence: Improvement outcome evidence
Common reasons for a PARTIAL answer
- 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.
- 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.
- A change was made but wasn't genuinely measured to confirm it produced real improvement.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Improvement project review | Reviews the practice's genuine, ongoing quality improvement effort, however small in scale. |
| ASK | Relevance interview | Asks the physician how the improvement effort relates to a real, identified gap in this specific practice. |
| DOCUMENT | Outcome evidence review | Reviews evidence of genuine, measurable change resulting from the improvement effort. |
Supervisor tips
- 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.
Evidence base
[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.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
7.4
Staff, However Few, Receive Real, Documented Training for Their Actual Role
Non-Negotiable
Every staff member, however few the practice employs, receives genuine, documented training specific to their actual role — not informal, on-the-job learning alone with no structured content or verification of competency.
In plain terms: Every staff member — even if there are only two — has documented training for what they actually do: the receptionist for triage, the nurse for the tasks she performs.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
In a small practice, staff do many things: the receptionist triages, the nurse gives vaccinations and dresses wounds, the practice manager handles data protection. Each task requires training, and informal learning is not training. Documentation matters: what training, when, by whom, and when it is due for refresh. The evidence that a nurse is competent to give a vaccine is a training record, not 'she's been doing it for years.' The evidence that the receptionist knows red flags is a signed session record. Two staff, two training files, current.
What good looks like
- Every staff member receives genuine, documented, structured training.
- Competency is genuinely verified, not assumed from time in role.
- Training is genuinely refreshed periodically, not a one-time event.
Common failure modes
- Training relies entirely on informal, on-the-job learning with no structure.
- Competency is assumed from tenure, never actively verified.
- Training happens once and is never revisited.
Worked example
In practice
A single-doctor health centre with one nurse and one receptionist.
BeforeThe nurse had learned on the job. No training records existed. The receptionist had never had any training beyond 'answer the phone.' When the Coordinator asked what the nurse was trained to do, the answer was 'everything she does.' Vaccination competency, wound care, BLS — none documented.
ActionA training needs list was written for each role from their actual duties. Each staff member now has a training file: BLS (both), vaccination competency (nurse), wound care (nurse), red flag triage (receptionist), data protection (both), infection control (both), safeguarding (both). Training was obtained from the regional health authority and online providers. Each item has a completion date and a refresh date.
AfterThe Monitor reviewed both training files: complete for current duties with refresh dates. Verified.
If you are starting from zero — do this first
- List every task each staff member does.
- For each task, what training exists? Write the gaps.
- Obtain training for the top three gaps this quarter.
- Keep a file per person with dates.
The most common mistake: Accepting 'she's always done it' as competency — experience without training is habit.
Self-assessment questions
1. Does every staff member receive genuine, documented training specific to their actual role? — Real, structured training with documentation, not informal on-the-job learning alone.
Evidence: Staff training record
Evidence: Staff training record
2. Is competency genuinely verified, not simply assumed from time spent in the role? — Real, active verification, not an assumption that tenure alone confirms competency.
Evidence: Competency verification record
Evidence: Competency verification record
3. Is training genuinely refreshed periodically, not completed once and never revisited? — Real, ongoing training, not a single initial session treated as sufficient indefinitely.
Evidence: Ongoing training schedule
Evidence: Ongoing training schedule
Common reasons for a PARTIAL answer
- 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.
- 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.
- Training happens but competency verification relies on informal observation rather than a genuine, structured check.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Training record review | Reviews documented, structured training for every staff member, however few. |
| DOCUMENT | Competency verification review | Reviews evidence that competency is genuinely verified, not assumed from tenure. |
| DOCUMENT | Ongoing training review | Reviews whether training is genuinely refreshed periodically. |
Supervisor tips
- 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.
Evidence base
[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.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
7.5
Incident Reporting Leads to Genuine Learning, Not Just Documentation
Non-Negotiable
When something goes wrong or nearly goes wrong, the practice genuinely reviews what happened and why, with real, documented change resulting where warranted — not an incident logged and filed without any real reflection or resulting action.
In plain terms: When something goes wrong or nearly goes wrong, the practice looks at why and changes something — the review is documented and the change is real.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Full | Full | Full | Full |
Why this matters
A small practice has incidents like any other: the wrong vaccine, the missed result, the medication error, the near-miss at reception. What distinguishes a learning practice is what happens next. Not blame, not a note in a file — a short structured review: what happened, why, what will change, who will make it happen. Documented on one page. Then the change is made and checked. Three such reviews a year is a learning system. A practice that records incidents and does nothing has a filing cabinet.
What good looks like
- Real incidents receive genuine review of what happened and why.
- Review genuinely results in documented change where warranted.
- Near-misses receive the same genuine attention as actual incidents.
Common failure modes
- Incidents are logged without genuine reflection on cause.
- Review happens but doesn't translate into any real, resulting change.
- Near-misses are dismissed because no actual harm occurred.
Worked example
In practice
A 4-room health centre that recorded incidents in a book.
BeforeThe incident book had 12 entries in two years, each a description with no analysis and no action. The same medication error (wrong strength dispensed) appeared three times. Nobody had asked why.
ActionA one-page incident review template was introduced: what happened, contributing factors, root cause, action, owner, date, follow-up check. The recurring dispensing error was reviewed: two strengths of the same drug were stored side by side. They were separated and labelled. The error has not recurred. Reviews are discussed at the monthly practice meeting. Near-misses are actively encouraged.
AfterThe Monitor reviewed six completed incident reviews with actions implemented and checked; the incident log showed near-misses now reported. Verified.
If you are starting from zero — do this first
- Read your last five incidents. Was anything changed as a result?
- Create a one-page review template: what, why, change, who, when.
- Review the next incident with it.
- Check that the change was made.
The most common mistake: Recording incidents without reviewing them — the same error repeats because nobody asked why.
Self-assessment questions
1. When something goes wrong or nearly does, is there genuine review of what happened and why? — Real, active reflection, not an incident simply logged and filed.
Evidence: Incident review record
Evidence: Incident review record
2. Does this review result in genuine, documented change where warranted, not review without action? — Real, resulting change, not reflection that doesn't translate into any actual adjustment.
Evidence: Resulting change documentation
Evidence: Resulting change documentation
3. Are near-misses genuinely reviewed with the same seriousness as actual incidents, not dismissed because no harm occurred? — Genuine attention to near-misses, not only events that actually resulted in harm.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- Review happens for significant incidents but not consistently for smaller, less dramatic ones. — Smaller incidents can still reveal genuine, real patterns worth understanding.
- 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.
- Near-misses are occasionally reviewed but not as a genuine, consistent practice.
Implementation plan
| When | What |
|---|---|
| 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. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Incident review record review | Reviews evidence of genuine reflection on what happened and why for real incidents. |
| DOCUMENT | Resulting change review | Reviews whether genuine, documented change resulted from incident review where warranted. |
| ASK | Near-miss attention interview | Asks the physician how near-misses are genuinely reviewed, not just actual incidents. |
Supervisor tips
- 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.
Evidence base
[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.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.