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Pharmacy QOF 2009/10

Further guidance

All documentation required prior to the review visit should be submitted to the PCT one month in advance of the visit, unless otherwise stated.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/3/2010. Evidence should be returned to your allocated PCT QOF assessor:

NHS Doncaster

White Rose House

Ten Pound Walk

Doncaster

DN4 5DJ

PM1 -Evidence to be submitted prior to the review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

SOP detailing the protocol for dealing with emergency situations – signed by all staff members.

Evidence that each member of staff has attended life support training within the last 18 months. This should include at least three members of staff having undertaken defibrillator training within the last 12 months. This information should also be included in the locum induction pack.

Each pharmacy should display a poster to highlight that a defibrillator is held on site and that staff are appropriately trained. A poster has been provided to be adapted for you pharmacy:

Evidence that this information has been shared with local health providers (Dentists, GP’s, Opticians). This could be a copy of a letter to the provider, for example.

PM2 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/3/2010.

Evidence is required in the form of copies of the minutes from the pharmacy quarterly review meeting at which patient complaints (both verbal and written), suggestions, niggles and grumbles have been discussed. Minutes should list the staff that attended the meeting, the date that it took place, a description of the complaint, lessons learned and changes to be made as a result.

PM3 -No evidence required from the Pharmacy in advance of the visit. Evidence will be obtained from NHS Doncaster Datix incident management system.

A minimum of 3 SEAs should be submitted to NHS Doncaster as detailed below:

Corporate Services Team

NHS Doncaster

White Rose House

Ten Pound Walk

Doncaster

DN4 5DJ

SEA reporting template:

PM4 - No evidence required from the Pharmacy in advance of the visit.

Information relating to this indicator will be provided by QMAIT.

PM5 – No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

Doncaster Safeguarding Children and Doncaster Safeguarding Adults procedures should be accessible to all staff within the pharmacy.

A local policy should be on display within the dispensary and included in the locum pack.

Members of staff will be questioned about the local policy to ensure understanding and also about the location of the Doncaster policies.

PM6 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

A written procedure should include the following:

  • Back up and verification of data, including the frequency of back-up
  • Storage of data on and off site
  • Authorisation to load programmes
  • A contingency plan to explain the procedure for accessing data offsite if the pharmacy is unable to open – this should be more than providing a contact number to a support site

If this indicator was achieved last year the policy may need to be amended to reflect revised criteria.

PM7 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

A written policy should include:

  • Hand-washing poster – this should be on display
  • Needle-stick injury poster – this should be on display
  • Protective clothing
  • Cleaning schedule and signed cleaning rota
  • Date checking of stock
  • Review date

The dispensary, staff room, shop, stockroom and toiletareas will be checked during the visit.

Cleaning schedules should be available for the previous 12 months and will be checked at random during the visit.

If this indicator was achieved last year the policy may need to be amended to reflect revised criteria.

PM8 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

A written policy should reflect current legislation and guidance and should include:

  • The separation of liquid and solid waste
  • Clinical, hazardous and domestic waste
  • Consignment note monitoring

If this indicator was achieved last year the policy may need to be amended to reflect revised criteria.

PM9 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

A written policy should include:

  • The definition of inappropriate prescribing and excessive patient return
  • Submission of a high quantity drug form to medicines management (below)
  • Discussion with the prescriber where appropriate

N.B. only the medicines management form needs to be submitted this year – no SEA is required as well. Policies approved for last years QOF may need to be amended to reflect revised criteria.

PM10 – No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

Pharmacies should respond to at least 80% of safety alerts. Records of responses are held within the NHS Doncaster QOF team therefore no evidence is required from Pharmacies.

Responses must be sent within 14 days of receipt and an auditable trail should be evidenced. NHS Doncaster must be made aware of changes to recipient details

PM11 – No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

NHS Doncaster PM11 form will be used as an assessment checklist during the review visit:

The pharmacist should also be aware of the Doncaster Accountable Officer.

Evidence should also be made available of any incorrect or missed balances and that they have been reported to NHS Doncaster.

PM12 -Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

Locum induction pack should be submitted prior to the review visit and should include the following:

  • Pharmacy safeguarding policy (flowchart) for children and vulnerable adults
  • Needle-stick injury policy
  • Information on Doncaster Accountable Officer
  • Other health facilities within the local area:
  • Out of hours service
  • Emergency dental service
  • Emergency optometrist
  • Local hospitals
  • Contact details of Pharmacists in Doncaster who provide local enhanced services – EHC, needle exchange, palliative care and minor ailments
  • Signposting document
  • A review date

This information can be found in the attached Signposting document:

The locum on duty log should show regular checking mark, contact details, signatures and knowledge of SOPS for all locums. The introduction of the Responsible Pharmacists (see attached below) in October 2009 will be sufficient evidence of this criteria:

PM13 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

ACT should be clearly identified within the branch, the certificate displayed and revalidation explained.

Certificates should be no more than two years old and ACT signatures should be on all SOPs.

PM14 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

Temperature charts will be checked during the review visit – this will be done by selecting two random months from your annual records. 100% of checks should be evidenced to achieve this indicator, i.e. temperatures checked on every day that the pharmacy is open and signed by the person taking the reading.

If a temperature result is outside of the 2-8 degree range then the appropriate follow up should be evidenced:

  • Contact manufacturer
  • SEA to NHS Doncaster
  • Staff discussion

PM15 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

During the review visit 10 anonymised PMRs should be evidenced by the assessors which must demonstrate where specific advice/counselling has been provided and recorded.

PM16 - No evidence required from the Pharmacy in advance of the visit. Evidence will be obtained from NHS Doncaster Research Champion.

The pharmacy can demonstrate that they have undertaken the necessary preparations to participate in PCT led research projects and become "research ready":

The Pharmacy will be asked to name a Research Lead and this information should be shared with NHS Doncaster.

The Pharmacy must attended a research training/awareness event, of which all Pharmacies will be informed of as soon as further information is available.

The Pharmacy must responded to communications from the research team. Communications will be monitored by the research team and shared with the assessment team at the end of the year.

The Pharmacy must make a declaration to the Research Team that they are ready to undertake research projects. This information will be shared with the assessment team at the end of the year.

PM17 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

Evidence for this indicator should be in the form of a written appraisal system and documented evidence that appraisals take place. This should include a schedule of staff appraisal dates an example of appraisal documentation used within the practice and personal development plan. A definition of appraisal is provided below:

Appraisal is a constructive opportunity to review performance objectives, progress and skills and identify learning needs in a protected environment.

The learning needs identified may be personal to the appraise and/or organisational learning needs which the appraise has agreed to fulfil.

The outcomes of the appraisal should be a written action plan agreed between appraiser and appraise which could include a personal learning plan for the appraise.

In addition the opportunity could be taken to review and update the appraises job description.

A template, which also includes guidance, has been provided that may be adapted for your practice:

PM18 -Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

Evidence is required in the form of an action plan detailing how the pharmacy will implement recommendations and guidance issued by NPSA. Evidence of how such guidance has been implemented should also be demonstrated and discussed during the review visit. A template has been provided help you record the relevant information required to achieve this indicator.

Examples from last years guidance are Warfarin, Opiates and Methatrexate

PE1 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

Total number of MURs undertaken will be obtained from data received from PPA – please be aware that QOF achievement is based on the number of reviews carried out between 01/02/2009 – 31/01/2010.

200 MURS = 1 point

300 MURs = 2 points

400 MURs = 3 points

The number of quality MURs carried out for the two chosen groups (patients taking Warfarin and patients taking more than 10 medications) will be checked during the review visit.

1 point will be awarded for 5 quality MURs for patients taking Warfarin

2 points will be awarded for 10 quality MURs for patients taking Warfarin

1 point will be awarded for 5 quality MURs for patients on 10+ medications

2 points will be awarded for 10 quality MURs for patients on 10+ medications

PE2 – Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

A written procedure should be in place and should detail:

  • Communication with surgeries regarding service sign up
  • Identifying suitable patients and advantages of the service to those patients
  • Recording on PMR where the service has been discussed with a patient

Policies approved for last years QOF may need to be amended to reflect revised criteria.

PE3 - Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

Evidence must be submitted to demonstrate that the pharmacy has undertaken an annual patient survey and having reflected on results will produce a written action plan to set priorities for the next 12 months. This should include:

  • Identify the priorities
  • How the pharmacy will report the findings of the survey to patients - (posters and information leaflets)
  • Describe the plans for achieving the priorities, including indicating the lead person in the branch

PE4 - Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

The pharmacy has a robust prescription ordering service which should be demonstrated during the review visit. The system and written procedure should be auditable and should include:

  • Requests for repeat prescriptions are initiated by the patient or their carer
  • Prescriptions must not be requested from a surgery before obtaining the patients' or their carers consent
  • The pharmacist must be authorised to receive and dispense prescriptions
  • Any prescription received to which the pharmacists is not authorised to dispense must be returned to the surgery for collection by the patient or carer, or be directed to the pharmacy authorised to receive it.
  • Where items are over/under ordered the prescriber is consulted

Policies approved for last years QOF may need to be amended to reflect revised criteria.

PE5 - Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

The pharmacy should demonstrate a robust procedure for the prescription collection service. The system and written procedure should be auditable and should include:

  • Consent to receive patients prescriptions
  • The request for ongoing consent must be from the patient or their carer and procedures must exist for maintaining records of the initial request for the service
  • Explanation to the patients, or their carers, what the service involves.
  • The time period required to collect/receive and dispense prescriptions
  • Signature of the collector to acknowledge receipt
  • Record of number of forms for each patient
  • Where applicable - prescriptions that are sent by fax to other pharmacies

Policies approved for last years QOF may need to be amended to reflect revised criteria.

PE6 -Evidence required in advance of review visit.

If the evidence is not available at the time of the visit this must be submitted to your assessor before 31/03/2010.

There is a robust procedure for the Prescription Delivery Service and this should be demonstrated during the review visit. A written procedure should be submitted prior to the review visit and should include:

  • Consent is gained from the patient and appropriate records of the request are kept.
  • Details of all deliveries are recorded and signed for on receipt.
  • The service caters for any special security/storage requirements of the medicine
  • Process of alerting patients to any concerns with prescription and who to contact at Pharmacy for more information.
  • CD deliveries are recorded separately and evidence of who signed for them relayed back to Pharmacy for recording in CD register.
  • Patients prescribed anticoagulants receive appropriate verbal and written information
  • Patients’ blood clotting (International Normalised Ratio, INR) is being monitored regularly and that the INR level is safe before issuing or dispensing repeat prescriptions for oral anticoagulants.
  • A note left for those not in on how they can pick up their prescription.
  • Recording of exemption status and collection of prescription fees due
  • A verifiable audit trail which can also be demonstrated

Policies approved for last years QOF may need to be amended to reflect revised criteria.

PE7 - No evidence required from the Pharmacy in advance of the visit. Evidence will be checked during review visit.

The pharmacy must demonstrate the percentage of on duty time for an accredited active pharmacist. This will be evidenced by checking signed logs & locum logs from May and November 2009. The pharmacists should also be signed up to Doncaster Patient Group Direction.

Achievement will be awarded as follows:

  • A trained accredited and active pharmacist should be on duty 75% of the time that the pharmacy is open (3 points)
  • Or 50% of the time that the pharmacy is open (1 point)

If you have any queries with any of the information provided within this guidance please contact Jenny Wyllie, details below:

Jenny Wyllie

Primary Care Quality Improvement Manager

NHS Doncaster

White Rose House

Ten Pound Walk

Doncaster

DN4 5DJ

Direct telephone: 01302 566200

Email: