Section C:

Clinical practice systems

Section Contents Page Number

Indicator Group 7: Screening (early detection), surveillance and
audit of clinical systems and implementation of clinical practice
guidelines (for the identification and management of patients at
risk for preventable diseases, with chronic diseases, with cancers,
and with mental health problems)

Indicator C.7.1C5

The practice has agreed policies for screening, surveillance and audit

Indicator C.7.2C8

The practice has an effective database of registered patients for screening,

surveillance and audit

Indicator C.7.3C10

The practice uses evidence-based clinical practice guidelines to ensure

consistent high quality health care

Indicator C.7.4C13

The practice has a regular appropriate review of prescription medications

Indicator Group 8: Applying surveillance and audit to outcome
indicators

Indicator C.8.1 C15

Smoking cessation

Indicator C.8.2 C18

Diabetes mellitus

Indicator C.8.3 C21

Hypertension

Indicator C.8.4 C24

Stroke or transient ischaemic attacks (TIAs)

Indicator C.8.5 C27

Secondary prevention in coronary heart disease (CHD)

Indicator C.8.6 C30

Anticoagulation medication

Indicator C.8.7 C32

Mental health

Section Contents Page Number

Indicator C.8.8 C35

Benzodiazepines for older patients

Indicator C.8.9 C37

Postmenopausal bleeding

Indicator C.8.10 C39

Asthma care (patients diagnosed with asthma - defined as those who had one

repeat prescription of a beta 2-agonist in the past year, who filled a prescription

for long-term control of asthma)

Indicator C.8.11C42

Chronic obstructive pulmonary disease (COPD)

Indicator C.8.12 C45

Epilepsy

Indicator C.8.13 C48

Hypothyroidism

Indicator C.8.14 C50

Cancer

Indicator C.8.15 C52

Sore throat

Indicator Group 9: Clinical practice systems and life cycle issues

Indicator C.9.1 C54

The practice provides comprehensive care for children

Indicator C.9.2C56

The practice has an effective system to identify and record childhood and

adolescent immunisations

Indicator C.9.3C59

The practice has an effective system to identify and record adult immunisations,

including flu vaccine

Indicator C.9.4C61

The practice provides comprehensive care for cervical screening

Indicator C.9.5C63

The practice provides comprehensive care for chlamydia

Indicator C.9.6C65

The practice provides comprehensive care for breast cancer screening

Section Contents Page Number

Indicator C.9.7C67

The practice provides comprehensive care for family planning

Indicator C.9.8C69

The practice provides comprehensive care for maternity services

Indicator C.9.9C71

The practice provides comprehensive care for adult patients

Indicator C.9.10C73

The practice provides palliative end of life care to patients

Section C

Clinical practice systems

This section is designed to assess quality clinical outcomes through screening, surveillance and audit of clinical systems and implementation of clinical practice guidelines. At this time, Ontario does not have identified clinical outcome priorities for family practices. For the purpose of the QIFP project, the following approach has been developed for identification of clinical outcomes:

  • Clinical outcomes where clinical practice guidelines reviewed by the Guidelines Advisory Committee in Ontario and guidelines developed by the Canadian Task Force on Preventive Health Care are published.
  • Clinical outcomes as defined by contracts between the MOH and PCNs, FHNs,FHGs, and others: pap smears, mammograms, flu vaccine and childhood immunisations.
  • Clinical outcomes proposed by Cancer Care Ontario as priorities: breast cancer, cervical cancer and colon cancer as priorities.
  • Clinical outcomes as outlined in the Mandatory Health Programs and Services Guidelines (December 1997) which includes chronic disease and injuries, family health and infectious disease categories.
  • Mental health outcomes as defined by Canadian Collaborative Mental Health Initiative and other key stakeholders.

The QIFP has developed a number of indicators (but not all) which can be used as a framework for assessing clinical outcomes. Some of the clinical outcomes that could be assessed include:

  • Substance abuse prevention: smoking, alcohol
  • Physical activity and healthy eating
  • Injuries: road safety, impaired driving, bicycle helmet use, correct use of car restraints, falls in the elderly
  • Chronic diseases: heart disease, stroke, cancer, chronic lung disease, high blood pressure, diabetes, osteoporosis, and many others
  • Early detection of cancer: breast, cervical, colon
  • Family health: improving planned pregnancy rates, contraception access, sexual assault and abuse, sexual orientation, prevention of sexually transmitted diseases
  • Reproductive health: preventing low birth weight, decreasing neural tube defects, pregnancy assessments
  • Child health promotion: childhood immunisation, injury prevention, parenting, developmental assessments
  • Infectious disease: HIV/AIDS, STDs, tuberculosis, SARS, rabies, vaccine preventable diseases through adult immunisation programs
  • Mental health: suicide, depression, schizophrenia, personality disorders
  • Prescription medication surveillance and monitoring

Section C: Clinical practice systems

Indicator Group 7 Screening (early detection), surveillance
and audit of clinical systems and
implementation of clinical practice
guidelines (for the identification and
management of patients at risk for preventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.1The practice has agreed policies for screening,

surveillance and audit

Criteria C.7.1.1There is a practice screening (early detection), surveillance and

audit programme

Section C – Clinical practice systems

Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.1

The practice has agreed policies for screening, surveillance and audit

The purpose of this indicator is to demonstrate that there is an effective system in place for screening, surveillance and audit of the practice

Criteria

C.7.1.1There is a practice screening (early detection), surveillance and audit

programme

Interpretation

  • The practice describes its screening, surveillance and audit policy (includes process - how patients are identified when they visit the practice, opportunistic screening, case alerts; and outcomes - rates of screening for cancers, high blood pressure, BMI, etc.)
  • The practice describes how it chooses priorities for screening, surveillance and audit
  • The practice describes how its team approach to screening, surveillance and audit
  • The roles of each team member in screening, surveillance and auditare clear (who is responsible, processes used, actions taken as a result, preparation of reports, etc.)
  • The practice describes the audits that have taken place in the last two years
  • The practice describes how it has addressed and plans to address challenges associated with screening, surveillance and audit
  • The practice describes how it captures changing information regarding personal and family history for screening, surveillance and audit

Further information

GAC Guidelines

Cancer Care Ontario and the Canadian Cancer Society - Call to Action: Cancer 2020 Summary Report

Cancer Care Ontario – Ontario Breast Screening Program

Cancer Care Ontario – Ontario Cervical Screening Program

Cancer Care Ontario - Colorectal Pilot Project

Pap Screening for Life – Guide to Screening by Nurses

Foundation for Medical Practice Education

Canadian Task Force on Preventive Health Care – Evidence-Based Clinical Prevention and Evidence-Based Resource Sheets

Section C: Clinical practice systems

Indicator Group 7 Screening (early detection), surveillance

and audit of clinical systems and

implementation of clinical practice

guidelines (for the identification and

management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.2The practice has an effective database of registered

patients for screening,surveillance and audit

Criteria C.7.2.1The practice has an effective system for maintaining an accurate

patient database

C.7.2.2The practice uses a disease identifying coding system which is

compatible with other commonly used data transfer systems

Section C – Clinical practice systems

Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.2

The practice has an effective database of registered patients for screening, surveillance and audit

The purpose of this indicator is to ensure that the practice is aware of the demographics of the population it serves and can access this information easily for screening, surveillance and audit purposes

Criteria

C.7.2.1The practice has an effective system for maintaining an accurate patient

database

Interpretation

  • The practice describes its patient database(includes age/sex register, patient profile, disease database) and how it ensures maintenance and accuracy of the database

C.7.2.2The practice uses a disease identifying coding system which is compatible

with other commonly used data transfer systems

Interpretation

  • Disease coding system (also OHIP coding and coding for incentives for prevention and chronic disease management, IHA has interesting layout for this)

Further information

From NZ

The advantage of Read Coding – recording data consistently, retrieving data more easily, data analysis, common clinical language, includes a range of diseases

Physician IT Program

Section C: Clinical practice systems

Indicator Group 7 Screening (early detection), surveillance

and audit of clinical systems and

implementation of clinical practice

guidelines (for the identification and

management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.3The practice uses evidence-based clinical practice

guidelines to ensure consistent high quality health care

Criteria C.7.3.1The practice uses evidence-based guidelines in its clinical

practice systems

C.7.3.2The practice has links with community resources to enhance

implementation of guidelines

C.7.3.3The practice has links with family resources to enhance

implementation of guidelines

Section C – Clinical practice systems

Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.3

The practice uses evidence-based clinical practice guidelines to ensure consistent high quality health care

The purpose of this indicator is to ensure that evidence-based clinical practices guidelines are applied consistently in the practice

Criteria

C.7.3.1The practice uses evidence-based guidelines in its clinical practice systems

Interpretation

  • The practice describes how it chooses to implement evidence-based guidelines (GAC, ICES, PBSG)
  • The practice describes how it keeps up to date with evidence-based guidelines
  • Patient audit process and outcomes are able to be assessed against the expected rates for the province (e.g. CCO, FHN contract, international standards)
  • The practice describes its clinical decision making and review process
  • The practice uses evidence-based guidelines for practice team education
  • The practice describes the processes used by the team to improve the use and uptake of guidelines in the practice

C.7.3.2The practice has links with community resources to enhance

implementation of guidelines

Interpretation

  • The practice describes its links with community resources to enhance implementation of guidelines
  • The practice describes how unique partnerships are developed with other organisations to enhance implementation of clinical practice guidelines

C.7.3.3The practice has links with family resources to enhance implementation of

guidelines

Interpretation

  • The practice describes how it utilises family resources in the management of diseases to enhance implementation

Further Information

GAC Guidelines

Institute for Clinical Evaluative Services (ICES)

Practice Based Small Group Learning Program

Canadian Task Force on Preventive Health Care

The Society of Obstetricians and Gynaecologists of Canada – Clinical Practice Guidelines

Canadian Medical Association (CMA) Infobase Clinical Practice Guidelines- the Canadian access to evidence-based clinical practice guidelines including patient guides and health professional summaries. These guidelines are produced or endorsed in Canada by a national, provincial/territorial or regional medical or health organization, professional society, government agency or expert panel.

Section C: Clinical practice systems

Indicator Group 7 Screening (early detection), surveillance

and audit of clinical systems and

implementation of clinical practice

guidelines (for the identification and

management of patients at risk for preventable diseases, with chronic diseases, with cancers, and with mental health problems)

Indicator C.7.4The practice has a regular appropriate review of

prescription medications

Criteria C.7.4.1There is a system in place for reviewing prescription medications

regularly

C.7.4.2There is an audit of medication reviews

C.7.4.3There is a policy on reporting adverse drug reactions

Section C – Clinical practice systems

Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk for preventable diseases, with chronic diseases, with cancers and with mental health problems)

Indicator C.7.4

The practice has a regular appropriate review of prescription medications

The purpose of this indicator is to demonstrate that the practice reviews its prescription medications regularly

Criteria

C.7.4.1There is a system in place for reviewing prescription medications regularly

Interpretation

  • The practice describes the system for medication review for all patients being prescribed four or more repeat medicines (excluding over-the-counter or topical medications)
  • The practice describes how drug-related problems are identified and resolved
  • The practice describes how correspondence with pharmacists regarding drug recommendations and concerns are documented and addressed

C.7.4.2There is an audit of medication reviews

Interpretation

  • The practice describes its audit of medication reviews

C.7.4.3There is a policy on reporting adverse drug reactions

  • The practice describes its policy on reporting adverse reactions

Further information

CPSO Policy of Prescribing Practices

Health Canada- Adverse Reaction Information

Health Canada- Adverse Reaction Reporting Forms

Section C: Clinical practice systems

Indicator Group 8Applying surveillance and audit to outcome

indicators

Indicator C.8.1 Smoking cessation

Criteria C.8.1.1The practice has reviewed the evidence-based clinical practice

guidelines for smoking cessation

C.8.1.2There is a register of patients’ smoking status

C.8.1.3The practice actively promotes smoking cessation strategies and

provides educational intervention programme information to

patients

C.8.1.4The practice has access to specific programmes that assist

patients with smoking cessation

C.8.1.5There is an audit of policy and charts

C.8.1.6There is a follow-up ofpatients involved in smoking cessation

intervention programmes

Section C – Clinical practice systems

Indicator Group 8 – Applying surveillance and audit to outcome indicators

Indicator C.8.1

Smoking cessation

The purpose of this indicator is to describe how the practice applies surveillance and audittosmoking cessation. The framework can be adapted and applied by practices to any clinical problem/issue priority.

Criteria

C.8.1.1The practice has reviewed the evidence-based clinical practice guidelines

for smoking cessation

Interpretation

  • The practice describes its review of the clinical practice guidelines for smoking cessation

C.8.1.2There is a register of patients’ smoking status

Interpretation

  • There is a patient register for smoking status
  • Smoking status is recorded and inserted into the medical record
  • There is a system to update the smoking status ofpatients, e.g. warning flags on computer system, practice policy, etc.
  • Smoking status is recorded in the records of patients over the age of 17

C.8.1.3The practice actively promotes smoking cessation strategies and provides

educational intervention programme information to patients

Interpretation

  • Educational materials are provided for patients (in the waiting room)
  • The practice describes how it promotes smoking cessation programmes and relevant information to patients (e.g. opportunistically, as part of ongoing care, other screening opportunities)
  • Smoking cessation advice/counselling is recorded for patients who use tobacco products

C.8.1.4The practice has access to specific programmes that assist patients with

smoking cessation

Interpretation

  • Knowledge of local programmes, how to access (e.g. website, pamphlets, 1-800 numbers, self-care, etc.) and link patients to existing programmes or people for support

C.8.1.5There is an audit of policy and charts

Interpretation

  • The practice describes its audit of smoking cessation

C.8.1.6There is a follow-up of patients involved in smoking cessation intervention

programmes

Interpretation

  • The practice describes how it follows up on patients involved in smoking cessation intervention programmes
  • The practice describes how it follows up on prescription and non-prescription medication use

Further information

Ontario – OMA Clinical Tobacco Intervention

GAC Guidelines

Section C: Clinical practice systems

Indicator Group 8 Applying surveillance and audit to outcome

indicators

Indicator C.8.2 Diabetes mellitus

Criteria C.8.2.1The practice has reviewed the evidence-based clinical practice

guidelines for diabetes mellitus

C.8.2.2The practice can produce a register of patients with diabetes

mellitus

C.8.2.3The practice actively promotes lifestyle modification to reduce

the risk of type 2 diabetes

C.8.2.4The practice has access to specific programmes that assist

patients with diabetesmellitus

C.8.2.5There is an audit of policy and charts

C.8.2.6There is a follow-up programme for diabetic patients

Section C – Clinical practice systems

Indicator Group 8 – Applying surveillance and audit to outcome indicators

Indicator C.8.2

Diabetes mellitus

The purpose of this indicator is to describe how the practice applies surveillance and audit to diabetes mellitus. The framework can be adapted and applied by practices to any clinical problem/issue priority.

Criteria

C.8.2.1 The practice has reviewed the evidence-based clinical practice guidelines