Is your practice effective?
Effectiveness refers to the ability to produce a desired output and in management it basically means getting the right things done. This is also one of the key questions asked by the CQC during their assessments and in this article we will look at how practices can and should run effectively for the benefit of both patients and the practice.
Audits are a great way to assess how well a surgery is being run and the CQC expects practices to routinely review the effectiveness and appropriateness of the care provided. There are several ways to carry out this exercise such as clinical audits, review of outcomes data, significant event analysis (SEA's), patient surveys, etc. and the level of care and services measured should match (or excel, it at all possible) what is considered to be best practice. The amount of data you can extract from audits is so useful that it can actually be used as baseline/benchmark for several purposes, including professional revalidation and annual staff appraisals.
Are you using NICE QS (Quality Standards) in your practice?
NICE QS are a set of standards (evidence-based statements of best practice) which are developed independently in collaboration with health and social care professionals, practitioners and service users. The standards address priority areas where there may be a variation in the quality of care provided and each standard includes a set of statements and information about how to measure progress. They usually summarise key recommendations for improving aspects of care.
During their assessment, CQC inspectors will look at how a practice considers quality improvements of the care and treatment they provide to their patients. This is part of their key line of enquiry (KLOE) E2: how are people's care and treatment outcomes monitored and how do they compare with other similar services?
All processes in a GP practice should be structured, robust, effective and safe to patients. This includes having systems and protocols in place for managing test results and clinical correspondence, for example. All staff should have access to training and support on the day to day implementation of the management of test results is important. Effective and clear communication with the patients is also essential and records should be kept of that communication.
The same safeguards need to be in place in regards to managing clinical correspondence where the joint working approach between clinicians and non-clinical staff is essential for effectiveness and best practice in task management.
Protecting vulnerable patients is a duty, responsibility and obligation of all staff in the NHS and as such, both clinical and admin staff should have a good understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (this still only applies to care homes and hospitals however if someone is being deprived of their liberty in community settings, local authorities may apply to the Court of Protection for authorisation) to ensure they are competent and able to act in the best interest of their patients.
The key principles affecting GP's are:
- Individuals are presumed to have capacity (meaning their individual rights should be respected and any decisions made on their behalf should be in their best interests).
- All practical steps must be taken to support someone in decision making (which includes providing them with accurate information so that the patient can make a decision regarding his choice of care, for example. In this case, open and clear communication between clinician and patient is also essential).
- A person is not to be treated as lacking capacity merely through making an unwise decision (for example, you would not refer a patient for a stop smoking clinic if they explicitly did not wish to engage despite being common knowledge that smoking is bad for your health. Likewise, although moderate exercise is considered healthy for most people, you would not try to force a patient to start exercising if they did not wish to regardless of their weight, age, health conditions, etc.). One should only provide useful advice, information and guidance if requested and when appropriate.
- Regard must be had as to whether an act or decision is the least restrictive of a person's rights and freedoms.
Other key areas of the MCA affecting GPs are:
- Independent mental capacity advocates (IMCAs).
- The ability for adult patients to make a lasting power of attorney (LPA).
- The establishment of a new Court of Protection.
- Court-appointed deputies. GPs need to be aware of people appointed to these roles and when to involve them in decision-making about patients who lack capacity.
Does the CQC have the right to check patient medical records during their inspections?
The answer is yes, they do. CQC has all the powers under the Health and Social Care Act 2008 (the 2008 Act) to access medical records for the purposes of carrying out their assessments (which includes checking that registered providers are meeting the requirements of registration).However, these powers should always balance against CQC's responsibilities under the Data Protection Act 2018, the Human Rights Act 1998 and the common law duty of confidentiality. Likewise, because that there are particular sensitivities about medical records held by GP practices (which may include very private and personal information such as personal relationships, mental and / or sexual health for example) these medical records reviews are usually done by a GP or a Nurse on the inspection team.
How about "clinical governance"?
When they inspect, CQC inspectors will make judgements about how effective is the clinical governance within a practice. This involves a systematic approach to maintaining and improving the quality of patient care and provides a framework for drawing together the different strands of quality improvement which includes clinical audit, clinical leadership, evidence-based practice and the dissemination of good practice, ideas and innovation whilst also addressing poor clinical performance.
All staff members should be involved but ideally this would be led by senior members of the practice who understand their responsibilities to improve the quality of care patients receive and are accountable for the quality of clinical practice provided by clinicians in the practice.
The basis for effective clinical governance is having data and information about how well a GP practice is performing, and using this information systematically to identify how to improve the quality of care provided. Examples of information that can be gathered to support discussions on clinical governance include:
- Unexpected deaths.
- New cancers and other life changing diagnoses.
- Significant events (both positive and negative).
- Patient complaints.
- Monitoring and adoption of best practice, e.g. NICE guidance and medicines alerts.
- Patient feedback (both positive and negative) and survey results.
- Prescribing performance.
- QOF and Enhanced Service performance data.
- Clinical audits findings.
- Education and learning, and sharing learning within the practice.
Last but not least in this article - the secret behind every top performing team: staff training...
CQC does not have a list of mandatory training for members of a practice team. This is because exact training requirements will depend on the role and specific responsibilities of practices and the needs of the people using the service.
Ultimately the practice is responsible for determining what mandatory and/or additional training staff needs to enable them to perform their roles and ultimately, provide excellent patient care and customer service. The inspection team will look at whether staff have the right qualifications, skills, knowledge and experience to do their job and how the practice identifies the learning needs of staff. However, as a provider you will be expected to show evidence of some examples of training such as basic life support, infection control, fire safety training, Mental Capacity Act and Deprivation of Liberty Safeguards and training to the appropriate level on safeguarding adults at risk and safeguarding children for both clinical and non-clinical staff.
Fact: the more emphasis you place in staff training, the better outcomes you will achieve for patients, staff development and for the practice as a whole.
Did you know...
Tree View Designs are committed to making it straightforward for practices joining together as at-scale models to meet the objectives of the STP (Sustainability and Transformation Partnerships) and of course to realise their own crucial goals. Our GP at scale websites incorporate a comprehensive range of features that will assist in this way. These include online forms, online appointment booking integration, news bulletins (also articles and newsletters), signposting tools and calls to action, links to healthcare partners and community services, digital management, monitoring tools and other useful resources (through the use of smartphone apps, etc.).
Jorge Goncalves (NHS Practice Manager)