Primary Care Quality (PCQ)
National Priorities for General Practice
End of Life Care
Cluster Guidance and Templates
2015/16
Authors: Primary Care Quality Team
Date: November 2015 / Version: Final v1
Publication/ Distribution:
GP Practices in Wales
Local Health Boards
Public Health Wales
Purpose and Summary of Document:
The purpose of this document is to support the GMS national priorities for general practice 2015/16 (section CND007W), end of life care (EOLC), as per the GMS Contract 2015/16 GP Cluster Network Development Domain.
This guidance should be read in conjunction with the latest QOF guidance for GMS contract Wales 2015-161. This PCQ guidance provides further guidance on completing a significant event analysis approach to assess delivery of end of life care and also provides two additional templates – one to collate learning points and actions at practice level, and one to collate these at cluster level for submission to the Health Board. This PCQ guidance aims to provide clusters with a method of collating these learning points in a quantitative manner.
Work Plan reference: Strengthening the public health impact of primary care
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Public Health Wales Primary Care Quality / End of Life Care
Overview
Our guidance advocates a system of collating the learning points and actions which can be summarised as follows:
Practice identifies all deaths occurring between 1st January 2015 and 31st December2015
A clinician reviews each case using ‘SEA’ principles (What happened? Why did it happen? What did you learn – good practice/areas for improvement? What will you do differently/Suggested actions?) See Annex 1 for the Individual Case Report template with a Reflection Tool to aid its completion.
Practice Team reviews individual case reviews/SEAs as a group. The salient points of cases are discussed with agreed learning points for each case. The team may also consider actions or interventions for each learning point, and record these.
Practice reviews outcomes of all SEAs/case reviews. Practice collates learning points and actions (which may be actions to be implemented at practice level or at cluster level) according to themes. See Annex 2 - Use PCQ thematic summary practice template to assist this process
Themes identified are submitted to clusters and discussed at cluster meeting
Cluster lead collates learning point themes and actions from practices into a cluster template in a quantitative format. See Annex 4 – Use PCQ thematic summary cluster lead template to assist this process.
At this stage, themes from individual clusters will be collated and reviewed by the Health Boards. Health Boards will then reflect on the actions taken in the relevant cluster/development plans. Feedback from this process should be provided to clusters/practices to help inform and guide subsequent SEA reviews and submissions for the national clinical priority
The Individual Case Report (SEA)
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Public Health Wales Primary Care Quality / End of Life CareUse of this template is specified in the Contract Guidance. A template taken from the Contract Guidance appears in Annex 1.
Use a significant event analysis approach to assess delivery of end of life care (with a particular focus on continuity of care) 1.
This analysis where possible, should include a review of 1:
Contacts by the multidisciplinary team in the last two weeks of life,
Review of the completion of DNACPR forms;
Review of the completion of out of hours handover forms;
Review of the availability of “Just in Case” boxes and
Review of Emergency admissions of patients at the end of life. Practice Thematic summary of SEA learning template (Annex 2)
It is suggested that a practice nominates a lead for collation of the learning points into a thematic summary for the practice. Primary Care Quality has developed a template to record these Completion of this template should take into account the need for concise and specific learning points to be readily identified, together with an idea of their frequency. It could then be a reference resource for the practice in its contribution to GP Cluster meeting discussions and could facilitate the completion of the GP Cluster Network Annual Report.
The practice thematic summary of SEA learning template (Annex 2) has 5 columns:
1.Learning point theme – the Individual Case Report Template (SEA) may have
one or more specific learning points (or none). Each learning point identified on
analysis of all the Individual Case Reports should be listed in the relevant column.
2.Specific learning points in each case - the prompts in the guidance provided on completion of the Individual Case Reports will provide suggestions of the specific learning points to be considered. There is no need to list any learning points that have not featured in any cases.
3.Number of cases with these themes - for each learning point theme there could be a numerical entry to reflect how many of the cases these learning points were relevant to. This will help to provide some ‘weighting’ to each learning point.
4.Action prompted at practice level – you may wish to provide some information about what action might be prompted by these learning points (from the completed individual case report templates) – the relevant GP may already have identified an action but it would be better to complete this following a multidisciplinary reflection with the practice team.
5.Action prompted at cluster level - encourages the practice to reflect on those learning points which may contribute to changes at cluster level that would help to inform its locality development. In other words, actions that may be beyond the practice’s individual remit to change but might apply where the cluster’s critical mass could influence.
At the end of the template, there is a section that recognises that practices may identify learning points that do not fit easily into the Learning Point Themes.
Cluster thematic summary of SEA learning template
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Public Health Wales Primary Care Quality / End of Life CareThe Cluster Lead may aggregate each of its practices’ Practice Thematic Summaries into a Cluster Thematic Summary using the template in Annex 3. It is included within this guidance to illustrate how individual practices’ templates need to be in a format that contributes to the easy completion of the Cluster Thematic Summary. Individual practices do not need to complete the Cluster Thematic Summary template – it is here just so they can see how their work contributes to this.
Further resources
Practices may find the following resources helpful in developing this work:
End of Life Care -Practice Report Example-See Annex 7A
20to%20Cluster%20Network%20Development%20Domain%202015%20-16%20%282%29.pdf
E-Learning for Health site- End of Life Care for All (useful educational resource) no/
Macmillan site for End of Life Care (good source of information for patients relating to many end of life issues)
Endoflife.aspx
All Wales Palliative Care website- valuable source of templates (Integrated Care Priorities/ Advanced Care Plans/ DNACPR forms etc) and other information in relation to palliative care; info/
REFLECTION TOOL
Please note that this is not a tick box exercise or a data collection, but is a tool to aid reflection and consists of a series of themed learning points. The issues arising from these learning points, when collated into themes, will help with the creation of focussed action plans that can lead to change at practice and cluster level.
Of course, in many cases only a small number of the pointers below would yield any comment of note. We want you to use your professional judgement and it is not expected that you address each and every bullet point.
Also, these discussion points are not exhaustive and you should add to them if you wish. Don’t forget things that went well; this is just as important as thinking about things that did not go well. Reflect on this in each case and identify any learning points that may help improvement in practice.
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Public Health Wales Primary Care Quality / End of Life CareANNEX 1
End of Life Care
Individual Case Report Template
Diagnosis
Date of diagnosis
Age of patient at diagnosis
Case Identifier / practice patient number
Date of death
Place of death
Date placed on practice Palliative Care Register
Date of this review.
1. What happened? Focus on the Patient’s/carer’s experience1. How did it happen?
Focus on how ‘well’ the End of Life care for the patient was organised?
Was the patient on the primary care practice Palliative Care Register at time of death? / Y / N
Preferred place of death discussed and recorded / Y / N
Anticipatory care considered and recorded (Not all patients will wish to have an anticipatory care plan) / Y / N
Did the patient have a named GP? / Y / N
OOH informed of patient entering onto the All Wales Integrated Care priorities for the Last Days of Life or other End of Life Pathway / Y / N
Ongoing Management – PRN (only when required) medications available for the following symptoms in anticipation of; pain/nausea & vomiting/agitation/respiratory tract secretions / Y / N
DNACPR discussed and recorded in the mediacl notes( Not all ptients will wish to complete a DNACPR) / Y / N
Were there any unplanned/unscheduled admissions during the final days? / Y / N
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Public Health Wales Primary Care Quality / End of Life Care3.What has been learned? What did the practice learn from reflection? Learning point 1:
Learning point 2:
Learning point 3:
Learning point 4:
4.What may you need to change at a practice level? (what has already changed)Which themes were identified as issues in this case review
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Public Health Wales Primary Care Quality / End of Life CareReflection Tool
1. What happened? – the focus here is on End of Life Care The patient’s / carer’s experience
Criteria for Integrated Care Priorities (ICP) for the Last Days of Life
Had the ICP’s use been clearly documented in the patient’s record?
In applying the ICP, had the exclusion of reversible causes of deterioration been recorded?
Had there been a record of the patient and/or family being made aware that the patient was in the last days of life?
Had it been documented that the ICP had been agreed by the clinical team?
Tissue donation
Had it been recorded what the patient’s /family’s wishes were with regard to tissue donation?
Had the patient’s priorities of care have been assessed and recorded?
Had the patient’s current medication been assessed and non-essentials discontinued?
Was there evidence that inappropriate interventions had been discontinued?
Had there been any un-planned / unscheduled admissions during the final days?
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
Had a DNACPR been completed and recorded for the patient? Had this been adequately recorded?
Symptoms
Hydration – had this been discussed and recorded with the patient / carer?
Pain
Had there been a record of how this was managed?
Had there been any record of adequacy of analgesia?
Were there any specific problems?
Nausea and Vomiting
Had there been a record of how this was managed?
Had there been any record of adequacy of anti-emetic?
Were there any specific problems?
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Public Health Wales Primary Care Quality / End of Life CareAgitation
Had there been a record of how this was managed?
Had there been any record of adequacy of interventions to reduce agitation?
Were there any specific problems?
Respiratory Tract Secretions
Had there been a record of how this was managed?
Had there been any record of adequacy of interventions to reduce respiratory tract secretions?
Were there any specific problems?
Nursing Assessment
Comfort measures
Had recording of vital signs been discontinued?
Pressure areas assessed? – were there any problems?
Condition of mouth assessed? – were there any problems?
Constipation assessed?
Spiritual / religious / cultural requirements
Had there been appropriate records made for these?
After Death
Did the patient die at the preferred place of death? If no, was there a missed opportunity?
Had the practice offered bereavement support?
Had the death been discussed at the following MDT meeting?
Had it been recorded what the family and carers had been informed as to what to do, who to contact when death occurred?
2. How did it happen? how well was the End of Life Care for the patient organised?
Administrative
Was the patient on the practice’s Palliative Care register? If not, was there a missed opportunity to have predicted death in the last 6 months?
Was the patient on the practice palliative care register at time of death? If not was there a missed opportunity to put the patient on the register closer to death?
How was the patient identified on the Palliative Care register? Was the Palliative Care Register entry coded? Was a template used?
Had the patient’s palliative care been discussed and reviewed regularly at multidisciplinary meetings?
Communication
Consider if communication within the team and with secondary care and other agencies had been optimal in the case reviewed.
Where information was not made available for inclusion in the GP record but was included in the patient’s integrated care record, if whether sharing of this information across agencies would have improved holistic care.
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Public Health Wales Primary Care Quality / End of Life CareCo-ordination
Had the patient been allocated a lead clinician?
Had the patient been allocated a lead district nurse and/or other palliative
care service?
Were specialist palliative care services involved at the appropriate time for
this patient?
Continuity of Care
Was notifying OOH that the patient was on the last days of life pathway a
concern in this case?
Was a “Just in Case” Box of medication important in this case?
Had there been any problem with obtaining out of hours care?
Advanced Care Planning
Had formal Advanced Care Planning been used and documented in this case?
Had Advanced Care Planning been documented in this case?
Could the documentation have been improved?
Were the patient / family / carers informed of the diagnosis and prognosis?
Was this documented?
Had the patient’s social needs been assessed and documented?
Had DS1500 been completed?
Had the patient’s mental state been assessed and recorded?
Had “Preferred Place of Care” been discussed with the patient / family / carer?
Had the patient’s preferences with regard to hospital admission been recorded?
Carer support
Had review of this case identified any problems with support of the carer(s)? Did the patient record clearly identify the carer?
3.What did you learn from reflection? - Thematic analysis of the issues
You will by now have identified which of these factors would be relevant to your case, and be able to determine how many of them represent learning points for you, your practice and your colleagues in the cluster. You will find it helpful to be concise at this point, using the themes outlined above, as this will facilitate your integration of these learning points into the Practice thematic summary of learning point template.
4.What will you change at a practice level? Collation of quantitative and qualitative data into the Practice thematic summary of learning points template. You will probably find it easier to do this by reflecting on what needs to change for each learning point. Remember that further information can be added here after discussion with your partners and with your colleagues.
Outline the actions agreed and implemented
Consider if a protocol has been or needs to be amended, updated or introduced
Are there things the individuals or the practice would do differently?
Include both clinical and administrative problems.
This work will link into parts of the Clinical Governance Practice Self Assessment tool (CGPSAT) and we recommend you refer to the relevant matrices listed in Annex 4 Within the CGPSAT you can use the “practice development plan notes” area at the end of each section to keep a record for your action plan.
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Public Health Wales Primary Care Quality / End of Life CareANNEX 2
Practice Thematic Summary of Learning TemplateEnd of Life Care
Practice identification and metrics
Practice Name
Practice W code
GP Cluster
Practice lead
Date submitted (dd/mm/yyyy) / __ /__ /____
Practice Summary of learning points
1. Learning Point Themes / 2. Specific learning points identified in each case / 3. Number of cases with these
themes (expressed as fraction of the
individual case reviews – e.g. 4/15) / 4. Action prompted
at practice level / 5 . Action prompted
at cluster level
All Wales Integrated Care priorities for the last days of life (ICP)
DNACPR
Nov 2015