The document outlines a scoring system for evaluating healthcare practices based on various criteria related to access to care, prioritization of treatment, appointment systems, and fair treatment policies. It details mandatory standards and a system for rating compliance, with a scoring range indicating full, substantial, partial compliance, and non-compliance. The accreditation status is contingent upon meeting specified compliance thresholds.

1. SCORING SYSTEM, RATING AND
ACCREDITATION STATUS

2. SCORING SYSTEM

3. SCORING SYSTEM
Criterion
No.
Survey Item Evidence of Compliance
Survey
or
Rating
Point Mandatory
Std 1 ACCESS TO CARE
Comprehensive, holistic patient care is only possible when a range of
services are both available and accessible, and all patients are able to
obtain timely care and appropriate advice /26 7

4. SCORING SYSTEM
Criterion
No.
Survey Item Evidence of Compliance
Surveyor
Rating
Points Mandatory
1.2 Priority of Care
The practice has a process for accepting
patients for treatment. Urgent cases
should be addressed as a priority.
Criteria for compliance:
Front desk staff can identify urgent cases.
a) List of conditions defined as
urgent is available (the clinic to
define based on the services
offered)
b) Staff able to identify urgent /
priority cases
Q
C
0, 2
Y, N
2

5. SCORING SYSTEM
Criterion
No.
Survey Item /
Evidence of Compliance
Surveyor
Rating
Points
Maximum
Score
1.1 Practice Policy
Documentation on practice policies available
vision, mission,
objectives, values and goals
in house billing policy
Q, C
0, 1, 2
0, 1, 2
0, 2
2
1
3
4
2
6
1.2 Priority of Care
a) List of conditions defined as urgent is available
(the clinic to define based on the services
offered)
b) Staff able to identify urgent / priority cases
Q
C
0, 2
Y, N
2 4
1.3 Appointment System
a) There is an appointment system
b) The duration of appointments is based on
treatment procedures
Q, C
S, C
Y, N
Y, N

6. SCORING SYSTEM
Criterion
No.
Survey Item /
Evidence of Compliance
Surveyor
Rating
Points
Maximum
Score
1.4 Practice Hours
a) Operating hours displayed to be seen from
outside the clinic
b) Information is available for patients to access
care out of normal surgery hours
O
Q
Y, N
0, 1, 2 3 6
1.5 Types of Service
a) List of services displayed in clinic
b) Patient information on services/ treatment
offered
O
Q, C
Y, N
0, 1, 2 2 4
1.6 Fair and Accessible Care
Practice does not discriminate on grounds of
i) Race, gender, social class, age, religion,
sexual orientation or appearance
ii) Disability or medical condition
S, Q
S, Q
Y, N
Y, N

7. SCORING SYSTEM
Criterion
No.
Survey Item /
Evidence of Compliance
Maximum
Score
Mandatory
Std 1 Access to Care
1.1 Practice Policy 12
1.2 Priority of Care 4 1
1.3 Appointment System 2
1.4 Practice Hours 6 1
1.5 Types of Service 4 1
1.6 Fair and Accessible Care 2
Total 26 7

8. SCORING SYSTEM
Std No. Survey Area Items Maximum Score Mandatory
1 Access to Care 13 26 7
2 Facilities & Equipment 24 48 12
3 Human Resource 21 44 11
4 Practice 39 112 16
5 Safety 43 18 39
6 Ethics 10 6 9
7 Governance 6 - 6
8 Quality Improvement Activities 5 12 2
Total 161 266 102
Sedation - Inhalation 21 18 17
Sedation – IV or Oral 22 8 20

9. RATING

10. RATING
Rating Actual Score % of Score
Full Compliance 266 100
Substantial Compliance 213 – 265 > 80 but < 100
Partial Compliance 160 - 212 > 60 but < 80
Non-Compliance < 160 < 60

11. ACCREDITATION STATUS

12. ACCREDITATION STATUS
Mandatory Items Rating Accreditation Status
All complied (102 items) Substantial Compliance
(> 212)
Full Accreditation
(4 yrs)
Partial Compliance
(160 – 212)
Delayed Accreditation
(6 mths)
Non-Compliance (<160) No Accreditation
Non-Compliance 1 – 20 Substantial Compliance Delayed Accreditation
Partial Compliance
Non-Compliance
No Accreditation
Non-Compliance > 20 No Accreditation