TEMPLATE 2006/07
(3rd Draft 13-12-06) / PRACTICE NAME: -
VISIT DATE =
Reviewed/analysed by:
Identifying Areas from QOF Submission to Address: Use the checklist to identify if any of the QOF submission requires further evidence / clarification or does not meet the required standards.
Where the questions are already included all reduced visits are being asked to verify / test the evidence received. This is generally done on the value of the points and the significance of the indicator to other PCT targets.
Check in the waiting room for information on arrival / Comments/ Actions- Information on smoking cessation services (QOF)
- Carers information (QOF)
- LES Poster (Minor Injuries) (Business review/ contractual requirement)
Range of information generally (QOF andBusiness review)
- Statement on boundary/ map and which patients they will register (Business review/ contractual requirement)
- Is there any feedback/ information on display about the patient experience survey or its results (QOF)
Reference / Indicator / Written Evidence / Area of concern for discussion?
CHECK THERE ARE NO INDICATORS THE PRACTICE IS NOT ASPIRING TO ACHIEVE
Records 9
(4 points) / For repeat medicines, an indicator for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004) / Results of a survey of patient records (minimum 50) using the supplied pro-forma ( lilac paper.) The survey should show an indication can be identified for at least 80% of repeat medications started after 1 April 2004
Records 15
(25 points) / The practice has up-to-date clinical summaries in at least 60% of patient records / This evidence will be provided via QMAS but where practices cannot evidence this electronically then a paper submission will be required. Please contact the PCT for a proforma to record this
Records 18
(8 points) / The practice has up-to-date clinical summaries in at least 80% of patient records / This evidence will be provided via QMAS but where practices cannot evidence this electronically then a paper submission will be required. Please contact the PCT for a proforma to record this
Records 19
(7 points) / 80% of newly registered patients have had their notes summarised within 8 weeks of receipt by the practice / Practice print out from population/ contract manager. Where practices cannot evidence this electronically then a paper submission will be required. Please contact the PCT for a proforma to record this
Records 20
(12points) / The practice has up-to-date clinical summaries in at least 70% of patient records / This evidence will be provided via QMAS but where practices cannot evidence this electronically then a paper submission will be required. Please contact the PCT for a proforma to record this
Info 7
(1.5 points) / Patients are able to access a receptionist via telephone and face to face in the practice, for at least 45 hours over 5 days, Monday to Friday, except where agreed with the PCO. Please note the PCT has not agreed any exceptions to this indicator with any of the practices. / Written summary of the times when telephone and face to face access to receptionists is available (usually, practice leaflet is sufficient)
Palliative Care 2
(3 points) / The practice has regular (at least three monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed / Description of the system that the practice has in place for initiating and recording meetings
Education 7 and 10
The practice has undertaken a minimum of 12 significant event reviews in the past 3 years / 12 significant event case reports using one of the supplied proformas – pink paper.
TEAM LEADERS SHOULD NUMBERSEAS FOR EASE OF REFERENCE
The practice has undertaken a minimum of 12 significant event reviews in the past 3 years, which include (if these have occurred) / 12 significant event review case reports using one of the supplied proformas. – pink paper.
- Any death occurring in the practice premises
- New cancer diagnoses
- Deaths where terminal care has taken place at home
- Any suicides
- Any patient admitted under the Mental Health Act
- Child Protection Cases
- Medication error
- A significant event, occurring when a patient may have been subjected to harm, had the circumstance/outcome been different (near miss)
Practice Specific Questions - (identified by the team leader) / Discussion/ Actions
Where the practice is aspiring to 12 SEAs in the past three years, double check if there have been any instances of the situations mentioned (above) if they are not included (e.g. most average sized practices will have had cancer diagnoses/death where terminal care has taken place at home, medication error etc.)
Are there any particular action points to review from previous SEAs?
Reference /
Indicator
/Written Evidence
/Area of concern for discussion?
Education 6(3 points) / The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team / Reports or minutes of team meetings where the practice has had an annual review of the practice complaints where learning points have been discussed, with a note of the changes made as a result
Ed. 8
(3 points)
Ed. 9
(3 points) / All practice employed nurses have personal learning plans which have been reviewed at annual appraisal
All practice employed non clinical team members have an annual appraisal. / Pro-forma indicating which clinical staff have had appraisals (white paper) and an anonymous example of a personal learning plan
Pro-forma indicating which other staff have had appraisals and when (white paper)
Medicines 11
(7 points) / A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed 4 or more repeat medicines – including topical preparations with an active ingredient
Standard 80% / Report of most recent clinical reporting system for QOF on status of medicines reviews
Medicines 12
(8 points) / A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines– including topical preparations with an active ingredient
Standard 80% / Report of most recent clinical reporting system for QOF on status of medicines reviews
Patient Experience 1. 10 Minute appointments (33 points)
The length of routine booked appointments with the doctors in the practice is not less than 10 minutes. (If the practice routinely sees extras during booked surgeries, then the average booked consultation length should allow for the average number of extras seen in a surgery session. If the extras are seen at the end, then it is not necessary to make this adjustment.)
For practices with only an open surgery system, the average face-to-face time spent by the GP with the patient is at least 8 minutes.
Practices that routinely operate a mixed economy of booked and open surgeries should report on both criteria.
Results of a survey carried out on 2 separate weeks of consultation length, or a computer printout which shows the average consultation length. Ask to see the appointment system and check a random selection of appointments to verify that 10 minute slots are being offered to patients.
Assessors Comments/ Queries
Reports indicate ______
Patient Experience 2,5,6 – Patient Survey Results
The practice will have undertaken an approved patient survey each year. (IPQ.GPAQ) / Evidence that the survey has been undertaken, including the date and methodology/minimum returns = 25 per 1000 registered patients
Results reflected upon (20 points)
Produce an action plan (30 points)
Are there enough patients surveyed (25 per 1000 registered) See business review information for practice population numbers.
If the practice has branches, have branch patients been included in the survey?
Team Leader to identify questions based on
(1)any significant changes in issues raised (NB they could be positive changes as well as negative ones)
(2)Any outstanding issues not addressed from last year (e.g. if not managed to sort issue X, what has prevented this)
(3)Discuss the rationale for the priority order identified in the Action Plan (PE6)
Did you contact your Non Executive Director about PE6 (discussing patient survey results) or did you work / are you working through a patient panel / patient representative group
If practice does not already have a patient panel, are there plans to develop one? If not, how will the practice demonstrate patient and public involvement?
How do you currently engage in patient and public involvement
Reference / Indicator / Written Evidence / Area of concern for discussion?
Palliative Care 2 / The practice has regular (at least 3monthly) multi-disciplinary case review meetings where all patients on the palliative care register are discussed. / Written evidence describing the system for initiatingand recording meetings.
NEW INDICATOR
Does the protocol cover the following:
How are meetings arranged?
How frequent are meetings?
Who comes to the meeting – how do they know when/ where?
What happens if you need a meeting before the next one is scheduled?
What things trigger a meeting before the next scheduled one?
Info 3
(1 point) / The practice has arrangements for patients to speak to GPs and nurses on the telephone during the working day / Written policy on telephone availability.
Info 5
(2 points) / The practice supports smokers in stopping by a strategy, which includes providing literature and offering appropriate therapy / Practice protocol on smoking cessation.
Mgt 2
(1.5 points) / There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes, and authorisation for loading programmes where a computer is used / Written policy covering information listed in the indicator
Mgt 8
(1 point) / The practice has a policy to ensure the prevention of fraud and has defined levels of financial responsibility and accountability for staff undertaking financial transactions (accounts, payroll, drawings, payment of invoices, signing cheques, petty cash, pensions, superannuation, etc.) / Written policy covering information listed in the indicator
Mgt 9
(3 points) / The practice has a protocol for the identification of carers and mechanism for the referral of carers for social services assessment / Protocol on the identification of carers and their referral for social services assessment.
CON 1
(1 point) / The team has a written policy for responding to requests for emergency contraception. / Written policy on responding to requests for emergency contraception.
CON 2
(1 point) / The team has a policy for providing pre-conceptual advice. / Written policy for providing pre-conceptual advice.
MAT 1
(6 points) / Antenatal care and screening are offered according to current local guidelines. / Written guidelines on antenatal care and screening
CS6 Audit of inadequate smears. - The practice has a policy for auditing its cervical screening service, and performs an audit of inadequate cervical smears in relation to individual smear-takers at least every 2 years
Provided the practice is one that achieved the CS6 Audit (see below for those who did not)
Has the practice seen an improvement in the rates of inadequate smears following any actions/ training they identified as a result of the Audit?
The following practices did not achieve the CS6 Audit last year
MIRZA, SAEED-AHMAD, PERLIK-KOLACKI, JAGADESHWARI (EVANS), HALDER, SUBHANI, ANSARI, FRANCIS. IF THIS VISIT IS NOT FOR ONE OF THESE PRACTICES, DELETE THIS LINE IN THE TABLE.
Ask
is the practice aspiring to achieve this indicator this year?
If yes, when will be the audit information be available?
CS7 Protocol for the management of cervical screening. Check protocol for the following areas
management of cervical screening -
Staff training
Management of patient call/recall
exception reporting
the regular monitoring of inadequate smear rates
The practice complies with current legislation on employment rights and discrimination (Business review/ contractual requirement)
When did the Practice Manager last attend an employment law update?
Discuss whether the PM feels they have sufficient knowledge and competency around Employment Law
Discuss whether the PM feels s/he had sufficient knowledge and competency. Has the practice identified any training needs, and if so how are these needs being addressed.
The practice complies with Health and Safety at work legislation ((Business review/ contractual requirement)
Ask when the Practice Manager last attended a HASAWA training update and if they access any support resources
Discuss whether the PM feels s/he had sufficient knowledge and competency. Has the practice identified any training needs, and if so how are these needs being addressed.
Anaphalaxis training – for those who deliver Vaccinations and Immunisations (business review contractual requirements)
When did those who deliver vaccinations and immunisations last have anaphalaxis training ?
(suggest if not in the last year this needs an update)
Gift Register - business review/ contractual obligation
Practices should have a register to record gifts that are estimated to be worth more than £100. This includes e.g. bequests in wills, hospitality (e.g. meals, conferences etc), general gifts. Sample register sent to practices in Autumn and available as part of the assessors analysis pack.
Has the practice established a register?
Ask to see it and whether any gifts have been recorded
Check if all staff (from reception to GPs and other clinical staff) are aware of the requirement to record gifts.
Indemnity and Registration: It is a contractual requirement that practice nurses have appropriate indemnity and registration and practice’s responsibility is to ensure this. (Business Reviews)
Where the practice have joint cover, check that the nurses have been accurately named (e.g. new names updated, old ones removed where required)
If there are any nurses whose registration has lapsed, they are not legally able to carry on working and it is the practice responsibility to address this.
Ask what systems there are for regularly checking that the registration and indemnity issues are covered?
Practice Leaflet – to be reviewed annually and updated accordingly (Business review/ contractual requirement)
When was this last reviewed (should be reviewed annually)
Is the copy you currently use up to date or do you need to include an erratum slip to update anything in it?
Control of Infection
- Has the practice had an Infection Control Audit carried out by PCT Control of Infection nurses?
- What infection control measures does the practice have in place? E.g. alcohol gel
Management 4 The arrangements for instrument sterilisation comply with national guidelines as applicable to primary care
there is no evidence submitted in the QOF papers for this indicator)
Ask if the practice is using/ intends to use single use instruments? (if intends to, when will this happen?) If practice using single use instruments only – they have achieved this indicator
If no or the practice use a mix of disposables but sterilise some instruments:
Ask who is responsible for running the sterilisation process.
You may need to move some of these questions to the Focus group session if it is e.g. the nurse and she is otherwise in surgery at this time.
Ask them to talk you through the procedure for using the steriliser and check against the following points:
- Does the practice use sterile water only in it and that once the bottle is opened the remainder must be discarded (can’t be stored – once a bottle is open the unused water is no longer sterile)
- At the end of the session all the water must be drained and left empty
- Instruments for minor surgery and coil fittings must be sterilised within 2 hours before being used (nb does not apply to e.g. speculums)
- is the steriliser is clean (no bodily fluids) and that there is a tight seal when closed
- Ask to see the practice log book that records daily that the required temp has been reached (134-137 degrees). Is it up to date? Has the standard temp. been achieved in all cases or if not, has any remedial action been recorded?
ACCESS (Access to a GP within 48 Hours, Access to a Health Care Professional*(usually Practice Nurse) within 24 Hours.
Refer to the business review information and use these prompts to develop practice specific questions:
Is the practice meeting 48 Hour GP access?
Is the practice meeting 24 Hours HCP access?