Achieving and maintaining Foundation Standard with confidence

Quality Manager Sue Aitken says the key to making the Foundation Standard easier to achieve and maintain is shifting the mindset from compliance at assessment time, to steady progress across the full three year cycle.

Pegasus Health supports practices to achieve Foundation Standard through both facilitators and assessors. Facilitators work alongside teams to prepare for assessment and strengthen systems, while assessors focus on reviewing evidence and confirming requirements are met.

“Meeting the requirements of the standard over the three-year period, with the right systems and processes in place, makes it much more manageable,” Sue said.

“There are 16 required policies. Pick five each year and review one policy every two months,” she said. “By the time assessment comes around, all your policies will be up to date.”

Training and certification requirements can also place pressure on practice teams, but Sue says this can be eased by implementing simple recording processes.

“Using a tracking tool like a spreadsheet gives clear visibility of where each team member is with training and certifications,” she said.

Training requirements usually fall into one-off obligations, such as Te Tiriti o Waitangi training or privacy, and recurring requirements, including annual practising certificates, CPR, and police vetting. Clear records make evidence submission simpler and highlight gaps where training has not been completed.

Sue also recommends using calendar or patient management system task reminders to schedule regular health and safety audits, six-monthly checks of residual current devices (RCDs), and evacuation and emergency drills. This helps practices stay on track year-round.

In Practice: Belfast Medical Centre

Belfast Medical Centre Practice Manager Debbie was new in her role when the practice’s Foundation Standard became due. At first, she underestimated how much work would be involved.

“I didn’t understand the enormity of it. I thought it was something we could wait on,” Debbie said. “Once we got into it, I realised there was a lot I just didn’t know.”

Working alongside the practice’s nurse manager and receptionist, Debbie started from the beginning. The team focused on understanding the standard and learning how to write and format policies correctly.

“It was a huge learning journey, making sure our policies covered everything they needed to,” she said.

Support from their Pegasus Foundation Standard facilitator, Sheryl Banks also helped the team make sense of the requirements.

“Sheryl didn’t just give us the answers. She worked with us and helped translate the standards into words we could understand.”

Their Pegasus assessor, Rachel McAllum, also helped identify gaps and strengthen the final evidence submitted.

“We would upload policies to Smartsheet, and Rachel would suggest small additions to make them stronger,” Debbie said. “We had clear guidance, and that made a big difference.”

Looking back, Debbie says the biggest lesson was starting early and spreading the work out.

“It’s not a box-tick exercise,” she said. “You need to start early and chip away at it. You can’t do this in two or three months.”

To stay on track, Belfast Medical Centre now breaks the standard into tasks and schedules them.

“I put everything into my calendar and task it out. Sometimes things get busy and something slips, but you know to come back to it.”

Debbie values the Foundation Standard for bringing multiple legislative requirements for the practice together in one place.

“It’s packaged up in the standard, which is helpful,” she said. “Having the standards guidelines gave us somewhere to start.”