1 References
The following documents are references to the Certification program:
· NSW Health - Medical Locum Agency Audit Guidelines 2009
· ISO9001-2008
2 Overview
NSW Health has developed a number of Audit Guidelines, which from the 17/08/2009 are mandatory for Locum Agencies contracted to NSW Health.
The program and the rules can also be open to agencies providing.
The program is based on the ISO9001 Quality Management Framework, with specific self assessment, checklist and report incorporating the NSW Health Guideline.
3 Definitions
Refer to NSW Health Standards and Conditions, and Guideline and Policies.
|
Program Summary Card |
|
Issue |
Program Rules/Comments |
|
Standard |
ISO9001 incorporating the NSW Health Medical Locum Agency Audit Guidelines 2009 |
|
Any other relevant documentation |
NA |
|
Target Clients |
Medical Locum Agencies |
|
Global-Mark output document |
Global-Mark Certificate of Approval |
|
Other Global-Mark output document |
NA |
|
Certificate Validity Period |
3 years, subject to yearly surveillance |
|
Certification Mark that can be used by the Client |
Global-Mark, Accredited Agency Program |
|
Can this mark be used on product? |
NA |
|
Periodicity of Post-certification Reviews |
6, 9, 9, 12 monthly |
|
Periodicity of Re-certification Review |
NA |
|
Steps to and Post-certification |
|
|
Application |
Yes |
|
Document Review |
Yes |
|
Pre-certification Review |
Yes |
|
Certification Review |
Yes |
|
Technical File Review |
Nil |
|
Follow-up Review |
Yes |
|
Post-certification Review |
Yes |
List of medical locums managed by the Agency
Agencies seeking or having Certification shall maintain a list of medical locums. Copy of the list shall be issued to Global-Mark before each audit/review (typically 2 weeks). Global-Mark will select from the list locum files to be audited.
Contract with Area Health Services
Agencies shall maintain a lot of current and active contracts with specific area health services. The list shall be presented to Global-Mark, typically 2 weeks before audits/review.
Privacy
Locum names will remain confidential within Global-Mark, and the agency seeking certification shall ensure that Locums have consented to their files being audits as part of this Quality Assurance Program.
5 Certification process
The Agency must supply a copy of their System Documents for review (typically Policy Manual and System Procedures, Organisation Chart).
These will be returned fully (or destroyed if requested by the Client) by Global-Mark after the review is completed.
Once the documents have been reviewed a letter will be sent to Client and next step in the process can start.
This can be done on site or off site.
5.2 Certification Review
Prior to the Certification Review, the Agency should complete the Self Assessment to ensure that it can demonstrate compliance with the requirements. Global-Mark will issue the blank self assessment.
The Certification Review of the Agency is conducted on site, and includes the review of records, interview of staff, management and locums. It may involve one or a team of Global-Mark auditors.
At the outcome of the certification review:
· Review findings will be presented at the exit meeting.
· A Report and review findings will be issued to the agency
A Certification decision (for/against certification) is made by the team, and is presented to Global-Mark management.
If no non-conformances have been raised and the recommendation for certification is accepted a Certificate of Approval will be issued. (This is an electronic certificate)
5.3 Post Certification Reviews:
The Agency shall be subjected to post certification reviews, on a 6, 9, 9, 12 monthly basis (and 12 monthly there after). The scope of each post certification review will be as presented in the Post Certification Plan, and previous Review Findings.
5.4 Reporting:
On completion of a review, Global-Mark shall, within 10 business days, provide a written report and recommendation(s) regarding the continuation of certification.
5.5 Transfers to GM
Clients seeking to transfer their certification to Global-Mark, need to supply a copy of their previous audit report(s), a valid and current JASANZ Accredited Certificate and complete a Client Agreement Form, however the following also applies:
Definition of a transfer
The transfer of certification is defined as the recognition of an existing and valid ISO9001 certification, granted by one JAS-ANZ accredited certification body, in line with the JASANZ Rules
6 What Documents/Records Are Needed To Understand This Program
In order to understand, our Program you should also access and be aware of the following documents:
· G-00: Welcome Pack
· MSP-00: Introduction to our Management Systems
· MSP-01: Nomenclature and Definitions
· MSP-24 Appeals
