Element 13 - Inducting staff

13.1.1 - Does the pharmacy need to complete the entire T13A Induction Checklist for every new employee, even a staff member only employed to make deliveries one hour per day?

Every new employee, no matter what their position or number of hours worked per week, is to be inducted into the pharmacy and an induction checklist completed.
If using the T13A Induction Checklist, the pharmacy is to determine which items are relevant to the position of the person being inducted and mark the other items as not applicable.
The pharmacy may produce its own induction checklist relevant to each position within the pharmacy. Each checklist might only contain the items relevant to the specific position. This is quite acceptable provided the pharmacy’s checklists contain all of the mandatory fields of T13A.


13.1.3 - The T13A Induction Checklist requires induction on specific policies and procedures to be completed at certain times. Is this mandatory?

Yes. There are certain policies and procedures on the Induction Checklist that are prefaced with a statement such as “to be completed on the first day of work” or “to be completed within the first five days of work”.
The policies and procedures in these sections are to be discussed within the specified time-frames.
Some information must be conveyed to a new employee either as soon as they commence work at the pharmacy or very soon after. For example, a new staff member must be informed of and agree to confidentiality requirements before being in a position to hear confidential information.
Some of the items within these sections may not be applicable to the employee’s position at the pharmacy and may be indicated as not applicable in the appropriate field.


13.1.4 - Is the P13B Workplace Surveillance Procedure mandatory?

P13B Workplace Surveillance is a mandatory procedure if a pharmacy has any surveillance arrangements (including listening devices) in use within the workplace. If this is the case, all employees must be notified and provided with a copy of the procedure as per Step 3 in the procedure.
In the event the pharmacy currently does not have workplace surveillance equipment, a procedure should be in place outlining how this will be implemented and communicated if required in the future.


13.2.1 - When implementing QCPP for the first time, do all employees - including long term staff members - need to have completed the pharmacy's induction program?

Yes. To support compliance with legislative and QCPP requirements, evidence all employees have participated in an induction program is required.


13.2.2 - What happens at assessment if there have not been any staff recruited in the last 2 years requiring induction?

In the event a pharmacy has not had any new employees recruited in the last 2 years the pharmacy will need to demonstrate they have a compliant induction process that has been used for existing employees, and will be used should there be a new recruitment in the coming 2 years.

If this evidence is provided on the day of assessment the QCPP Assessor will confirm the pharmacy is compliant and note the system has not been required to be used in the last 2 years within the assessment record.

The evidence required at assessment sometimes requires the Assessor to sight records for a maximum of five staff. Who chooses which staff member records the Assessor will view?

It is up to the Assessor to decide which staff member records they sight and will choose through a random audit approach. An Assessor may ask for records for a specific staff member when checking compliance.
Can I provide a declaration that evidence is stored off site to demonstrate that I am compliant with QCPP?

 No, Your assessor will need to sight evidence the pharmacy is meeting QCPP Requirements consistent with the evidence required by the QCPP Requirements (i.e. blue folder or digital equivalent).

In the event a pharmacy elects to store personnel files off site, the pharmacy will be required to ensure all personnel records are on site for the day of assessment to allow an assessor to randomly audit records.

 Does the assessor need to sight employee files, or does the Privacy Act prevent this from occurring?

 Yes, consistent with Program Rules 13 & 14, assessors are required to view records, including employee files to ensure the Human Resource System is consistent with QCPP requirements and is being utilised accordingly.
QCPP is not collecting personal or private information of employees rather seeking evidence to ensure the pharmacy’s Human Resources systems are operating in accordance with Australian Standard 85000 Quality Care Pharmacy Standard – quality management system for pharmacies in Australia. EY, including their staff and contractors are contractually required by QCPP to maintain confidentiality and privacy. This  should be highlighted to your employees prior to the commencement of every QCPP assessment in the opening meeting. In addition, it is expected Assessors are accompanied and observed by one of your employees at all times and are not accessing records in isolation.
QCPP has sought direct advice from our accrediting body to ensure QCPP is operating within the legislation and requirements of an accreditation body. The Joint Accreditation Scheme for Australia and New Zealand (JASANZ) have confirmed:

 "Certification schemes such as QCPP which include a field assessment as means of evaluating compliance, require the assessor to establish on the basis of objective evidence, that the client organization is employing/engaging appropriately qualified and trained staff to deliver the services that are relevant to the certification. To enable the assessor to draw correct conclusions it is expected that he/she will need to view records.

  The basis of this expectation is found in ISO/IEC 17021-1:2015 Clause which states:  Methods to collect information shall include, but are not limited to:

 a) interviews;
b) observation of processes and activities;
c) review of documentation and records.

 It is a condition of JAS-ANZ accreditation that certification bodies establish and maintain a confidentiality policy and that they require their assessors to sign a formal undertaking to abide by such policy.

 The QCPP certification scheme is operated by the Pharmacy Guild of Australia which is accredited by JAS-ANZ under ISO/IEC Guide 65. The conduct of QCPP field assessments is periodically witnessed by JAS-ANZ in order to verify adherence to Guild policies and procedures and accreditation requirements." 

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